• Risk Adjustment Coding Specialist

    Job Locations US-RI-Smithfield
    Req No.
    NHPRI Department
    755 - Medical Expense Management
    Regular Full-Time
  • Overview

    The Risk Adjustment Coding Specialist confirms any risk adjustment errors and findings. Coders will need to understand the basis for medical record documentation, origination from the provider of service and in alignment with dates of service, service codes and related HCC.


    • Confirm all risk adjustment diagnosis codes from acceptable provider documentation and in accordance with industry standards, CMS or HHS Risk Adjustment Guidelines
    • Adherence to current industry standard as defined in the ICD-10 guidelines for coding and correct reporting
    • Confirm accurate entry of risk adjusted codes into internal/external data based as defined by State, Federal or other Regulatory Agencies.
    • Support in documentation retrieval and review during Medicare or Exchange RADV Audits
    • Ability to support strategic direction for program operations, goals, metrics, tasks, timeframe and appropriate reporting and timing related to all National HCC Activities.
    • Identify and apply best practices to ensure accuracy of risk adjustment coding is consistent across in all markets served by Neighborhood Health Plan
    • Reconcile data to outcomes, and Risk Scores and Trending patterns to RAF Scores
    • Monitor risk adjustment relates activities including but not limited to risk adjustment program payments, encounter data submission and return files to ensure all tasks are completed in a timely manner and achieve expected outcomes
    • Support new initiatives in the develop and standardization of tools to be used to improve accuracy of coding and documentation that meet State and National Standards
    • Consistently exhibit behaviors and foster relationships with peers and internal stakeholders

    Regulatory Oversight and Quality Assurance:

    • Support the company’s quality assurance programs that monitor, audit and improve the quality of provider medical record documentation, diagnosis coding and the coding work of staff and vendors as relates to risk adjustment.
    • Support strategies for effective and regular monitoring and auditing to identify risks, improve quality and reduce risk stemming from CMS RADV audits.

    Provider Engagement, Training and Support:

    • In Partnership with Manager of Risk Adjustment, support internal departments in proper coding, on error rates associated with coding accuracy to ensure data is complete and accurate prior to submission to external agencies.
    • In conjunction with other departments, support programs that will enhance provider training and education of the HCC Risk Adjustment Process, Proper Medical Record Documentation and Diagnosis Accuracy.

    Analysis and Use of Results

    • Support Manager with Medical Management on the integration of prospective programs into care management processes and promote the use of risk adjustment programs to help facilitate care management.
    • Collaborate with Manager to project and monitor the impact of coding programs on CMS revenue for budgets and plans

    Enterprise Risk Adjustment

    • Support Manager in driving enterprise-wide risk adjustment initiatives.



    • Certified Professional Coder, Certified Risk Adjustment Coder, Certified Outpatient Coder, Claims Coders Certified Claims Specialty-Provider, Register Health Information Technology, or Registered Health Information Administrative Coding Certification required.
    • 2-3 years’ experience in Health Plan Operations to include Risk Adjustment Activities
    • Previous experience in risk adjustment coding activities in a Medicare, ACA or provider organization to include RAPs, EDPS, Edge Server, RADV Audits and all CMS, State and other regulatory Guidelines.
    • Must have experience in data entry of codes into database or software tools as prescribed by Neighborhood Health Plan
    • Proficiency in Microsoft Suite as well as various EMR (Electronic Medical Records) Systems.
    • Extensive knowledge in medical terminology and ability to research coding related questions
    • Requires advance technical knowledge in Physician, Multi - Specialty, Surgical, Hospital, Lab, Pharmacy or other related Code Sets
    • Knowledge of claims coding and payment methodology, associated with a Health Plan domain.


    • Claims System acumen
    • System knowledge of Amysis or Health Edge

    Organizational Competencies:

    • Judgment and Decision Making
    • Get Results
    • Collaboration and Teamwork
    • Business Awareness
    • Customer Focus

    Job Specific Competencies:

    • Attention to Detail
    • Continuous Quality Improvement
    • Planning & Organizing
    • Problem Solving & Analysis
    • Strategic Thinking & Alignment

    Flexible Work Arrangement:

    • Yes

    Telecommuting Arrangement:

    • Yes (1 day a week after 6 months of employment)


    Travel Expectations:

    • Local Travel Required


    Neighborhood is an Affirmative Action and Equal Opportunity Employer and all qualified applicants will receive consideration for employment without regard to race, color, religion, gender, sexual orientation, national origin, genetic information, age, disability, veteran status or any other legally protected basis.


    Neighborhood is committed to ensuring individuals with disabilities and/or those who have special needs participate in the workforce and are afforded equal opportunity to apply for jobs. If you would like to contact us regarding the accessibility of our Website or need assistance completing the application process, please contact us at recruiting@nhpri.org.


    Neighborhood is an EOE M/F/D/V and an E-Verify Employer


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