About this role
Role Overview
Lead the clinical evaluation of AI tools that improve hierarchical condition category risk scores and coding completeness across Medicare Advantage, Medicaid managed care, and ACA markets. This role combines deep HCC methodology and RADV audit experience with hands-on chart review to shape AI systems that enhance documentation capture, coding accuracy, and risk score integrity.
Key Responsibilities- Lead risk adjustment and HCC coding operations spanning Medicare Advantage, Medicaid, and ACA risk adjustment programs.
- Evaluate AI-generated HCC coding assignments and risk adjustment recommendations for clinical accuracy and regulatory compliance.
- Review medical records to ensure complete and accurate capture of HCC-eligible conditions, verifying that clinical documentation supports assigned codes.
- Conduct and oversee retrospective and prospective chart reviews aimed at optimizing risk scores.
- Manage RADV, Risk Adjustment Data Validation, audit preparation and response processes.
- Monitor risk adjustment key performance indicators, including HCC capture rates, risk score accuracy, and chart retrieval rates.
- Collaborate with clinical, coding, and compliance teams to improve documentation and coding practices for risk adjustment purposes.
- Ensure adherence to CMS risk adjustment guidelines, including RAPS and EDGE submission processes, and to Official Coding Guidelines.
- Annotate AI outputs and provide structured coding feedback to create and refine AI training datasets.
- Minimum 5 years of experience in risk adjustment coding, HCC coding, or Medicare Advantage coding operations, with at least 2 years in a leadership role.
- Deep expertise in CMS-HCC, RxHCC, and/or ACA HHS-HCC risk adjustment methodologies.
- Strong knowledge of ICD-10-CM coding guidelines as applied to HCC risk adjustment.
- Experience with RADV audit preparation and CMS compliance requirements.
- Familiarity with RAPS and EDGE submission processes.
- Exceptional written and verbal English communication skills.
- High attention to detail and the ability to identify coding inaccuracies and documentation gaps in AI-generated outputs.
- CRC, Certified Risk Coder, CCS, CPC, or RHIA credential.
- Experience with risk adjustment analytics platforms and chart retrieval systems.
- Background in a health plan, Medicare Advantage organization, or value-based care setting.
- Familiarity with AI-assisted HCC coding tools and experience evaluating AI-generated risk adjustment content.
- Experience presenting risk adjustment performance to actuarial or executive teams.
- Location: Remote.
- Employment type: Hourly.
- Rate: $110 per hour.
- Must be able to review medical records and verify that clinical documentation supports HCC-eligible conditions, as part of responsibilities that involve handling clinical documentation and audit-related materials.
- Contribute to the development of advanced AI systems in healthcare.
- Collaborate with a leading AI research organization on high-impact projects that influence the future of risk adjustment and value-based care.