Risk Adjustment Compliance Specialist, Principal

Your Role

The Risk Adjustment Compliance Specialist, Principal is responsible for ensuring organizational compliance with laws related to Risk Adjustment across our Marketplace (ACA), Medicaid and Medicare Advantage lines of business. This role involves auditing, monitoring, and evaluating risk adjustment processes, identifying areas of non-compliance, and recommending corrective actions. The Principal collaborates with internal teams and external partners to maintain the integrity of risk adjustment data and supports the development and implementation of compliance programs.

Your Knowledge and Experience

• Requires a college degree or equivalent experience. A degree in health care administration, business, public health, or related field is highly preferred
• Requires a certified Risk Adjustment Coder (CRC), Certified Professional Coder (CPC), Certified Coding Specialist (CCS), or equivalent credential
• Requires 10 years of relevant experience in Risk Adjustment, Healthcare Compliance, Medical Coding, or related area
• Requires strong knowledge of ICD-10-CM coding, HCC Risk Adjustment models (CMS-HCC and HHS-HCC), regulatory requirements, RADV audit documentation standards, and compliance standards
• Requires experience with data analysis, auditing, and reporting in a healthcare environment
• Requires excellent written and verbal communication skills, with the ability to convey complex information clearly
• Requires one to be detail-oriented, analytical, and able to manage multiple priorities in a fast-paced setting
• Requires proficiency in Microsoft Office Suite and relevant healthcare software applications
• Experience with ACA Marketplace (HHS-HCC) and/or Medi-Cal/Medicaid Managed Care Risk Adjustment programs is highly preferred
• Certification in Healthcare Compliance (CHC) is preferred