About this role
Role Overview
Help advance healthcare AI by evaluating tools that improve risk score accuracy, coding completeness, documentation capture, and risk score integrity across Medicare Advantage, Medicaid managed care, and ACA markets.
Key Responsibilities- Lead risk adjustment and HCC coding operations for Medicare Advantage, Medicaid, and/or ACA risk adjustment programs.
- Assess AI-generated HCC coding assignments and risk adjustment recommendations for clinical accuracy and regulatory compliance.
- Review medical records to confirm HCC-eligible conditions are fully and accurately captured when supported by clinical documentation.
- Conduct and oversee retrospective and prospective chart reviews to optimize risk scores.
- Manage RADV audit preparation and response activities.
- Monitor HCC capture rates, risk score accuracy, chart retrieval rates, and other risk adjustment KPIs.
- Partner with clinical, coding, and compliance teams to strengthen documentation and risk adjustment coding practices.
- Maintain compliance with CMS risk adjustment guidance, including RAPS and EDGE submissions, and Official Coding Guidelines.
- Annotate AI outputs and provide structured coding feedback for AI training datasets.
- At least 5 years of experience in risk adjustment coding, HCC coding, or Medicare Advantage coding operations, including 2 or more years in a leadership role.
- Deep knowledge of CMS-HCC, RxHCC, and/or ACA HHS-HCC risk adjustment methodologies.
- Strong understanding of ICD-10-CM guidelines as applied to HCC risk adjustment.
- Experience preparing for RADV audits and meeting CMS compliance requirements.
- Familiarity with RAPS and EDGE submission processes.
- Exceptional written and verbal English communication skills.
- Strong attention to detail and ability to identify coding inaccuracies and documentation gaps in AI-generated outputs.
- CRC, CCS, CPC, or RHIA credential.
- Experience with risk adjustment analytics platforms and chart retrieval systems.
- Experience in a health plan, Medicare Advantage organization, or value-based care environment.
- Familiarity with AI-assisted HCC coding tools and evaluating AI-generated risk adjustment content.
- Experience presenting risk adjustment performance to actuarial or executive teams.
- Remote, hourly engagement.
- $110 per hour.