Job Description

Position Purpose:  Responsible for the implementation of Risk Adjustment performance initiatives for the Health Plan, and strategic in-person day-to-day oversight of Health Plan in collaboration with Director of National Risk Adjustment.


Oversees and leads a remote field team while collaborating with ACO performance team, internal staff, physicians, and vendors on process improvement measures to identify members with risk adjustment opportunity. Manages a team that conducts prospective and retrospective audits of provider documentation to ensure complete risk adjustment coding data capture for the purpose of improving individual member risk score and quality outcomes for our members. Reviews multiple EHR systems for Risk Adjustment, CPT coding accuracy, HEDIS and risk adjustment coding opportunities. Manages members in identified patient population to ensure that operational workflows are in place to close gaps and ensure members are receiving quality care.


Provides instruction to providers and staff in abstracting codes effectively from medical records to ensure quality and timely care of our members as well as correct reimbursement. Works collaboratively between the health plan and the provider’s offices devising unique ways to identify and create strategies to improve interventions related to health care measures. Works with Special Investigation Unit (SIU) in identifying areas of potential fraud, waste and abuse.  Delivers education and develops action plan for physicians/clinics identified by SIU coders for specific coding outliers. Identifies areas in need of corrective action or education. Identifies, and facilitates implementation of strategies for sustained work process changes that facilitate complete and accurate clinical documentation. Collaboration with ACO performance team on implementation of best practices, measurement, and oversight related to risk adjustment coding.


Provide guidance in the assessment of HEDIS and CMS STARS quality measures by analyzing data, identify trends, summarize findings, and prepare/implement action plans to improve compliance. Reports will need to be prepared for business partners including health plans, physicians, and senior/executive leadership. Oversee the process and implementation of both concurrent and retrospective chart reviews. Responsible for all CMS submissions related to risk adjustment (e.g. encounter data, RAPS files, etc.). Develop and monitor tracking and measurement for CHE process. Oversee the utilization of appropriate clinical documentation to identify opportunities and ensure accuracy and completeness of clinical documentation use for measuring and reporting outcomes. Provide feedback to Executive and Senior management on provider education outcomes and targeted performance measurement. Quarterly Coder Audits, with written and verbal feedback.


Oversee communication with physicians and office staff on best practices for documentation of physician services. Develop mitigation plan with practices as needed. Acts as divisional consultant, and provides education for providers and office staff.


Health Choice exists to improve the health and well-being of the individuals we serve through our health plans, integrated delivery systems and managed care solutions. We strive to recruit and retain only the finest health care professionals with the highest levels of integrity, compassion and competency. If you are driven by your own personal commitment to these values and desire to work in a team-focused, collaborative and supportive environment - while still being valued for your individual strengths - Health Choice is the place for you.

Equal Opportunity Employer Minorities/Women/Veterans/Disabled



·    College degree (BSN) required

Years of Experience:  

·    Three (3) to five (5) years’ experience working in healthcare within or in collaboration with physician practices and at least three (3) years of coding experience

Work Related Experience:  

·    Clinical background preferred with one of the following certifications: CPC, CRC, CCS, COC, CCS-P, RHIA, CPMA or RHIT (CPC-I preferred)

Specialized Knowledge:  

·    Must have comprehensive understanding of the contents of a typical medical chart medical terminology and abbreviations, ICD 9 / ICD 10 coding conventions and guidelines, what constitutes adequate substantiation of a diagnosis, and appropriate providers, documents and facilities for proper code capture and clinical documentation

·    Knowledge of risk adjustment, Process Improvement techniques, quality improvement, and strategic planning

·    Strong knowledge and CMS and Commercial Health Plans

·    Strong knowledge of HEDIS measures and their requirements

Application Instructions

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