Senior Risk Adjustment Coding & Compliance Consultant

Blue Shield; Oakland (CA); Hybrid; USD 123,090 - 184,800; Full time

Benefits offered by this job

Hybrid work model

Job summary

Blue Shield of California seeks a Risk Adjustment Compliance Coding Specialist (Consultant) to ensure regulatory compliance across ACA, Medi-Cal and Medicare Advantage. You will review records, assign ICD-10-CM and HCC codes, conduct audits, and educate providers to improve documentation and compliance.

The role requires a bachelor’s degree or equivalent, CRC/CPC/CCS or equivalent credentials, and 6+ years in risk adjustment coding or related compliance fields.

Qualifications

• Requires a bachelor’s degree or equivalent experience.
• A degree in Health Information Management, Nursing, Health Administration, or related clinical field preferred.
• Certified Risk Adjustment Coder (CRC), Certified Professional Coder (CPC), or Certified Coding Specialist (CCS) or equivalent required.
• Minimum 6 years of experience in compliance audit, risk adjustment coding, medical coding or related field; Medicare Advantage/ACA/Medicaid experience preferred.
• Deep familiarity with compliance risk assessments, audits, and risk adjustment models.

Responsibilities

• Comprehensive Record Review of patient records to identify diagnoses affecting risk adjustment scoring.
• Assign ICD-10-CM codes including HCC based on CMS/HHS guidelines and payer requirements.
• Conduct quality audits, develop workplans and corrective actions for discrepancies and upcoding/downcoding.
• Collaborate with physicians and clinicians to clarify documentation and educate on best practices.
• Monitor regulatory updates and risk adjustment models to ensure ongoing compliance.
• Develop training materials and deliver sessions on risk adjustment principles and compliant documentation.
• Produce reports on audit findings, trends, and quality improvement opportunities for leadership.

Skills

ICD-10-CM coding

HCC coding

CMS/HHS guidelines

Medical coding auditing

Analytical skills

Communication

Education

Bachelor’s degree or equivalent experience

Health Information Management/Nursing/Health Administration preferred

Tools

EHR systems

Coding audit tools

Microsoft Office

Risk adjustment analytics software

Job description

Blue Shield of California seeks a Risk Adjustment Compliance Coding Specialist (Consultant) to ensure regulatory compliance across ACA, Medi-Cal and Medicare Advantage. You will review records, assign ICD-10-CM and HCC codes, conduct audits, and educate providers to improve documentation and compliance.

The role requires a bachelor’s degree or equivalent, CRC/CPC/CCS or equivalent credentials, and 6+ years in risk adjustment coding or related compliance fields.