Senior Risk Adjustment Coding Quality Assurance Specialist

Summary

Join Homeward in revolutionizing healthcare delivery in rural America! As a Senior Risk Adjustment Coding Quality Assurance Specialist, you will play a vital role in ensuring accurate and compliant Medicare Advantage risk adjustment coding processes. You will conduct quality assurance audits, optimize risk adjustment documentation, and maintain expertise in CMS guidelines. This role involves provider education, compliance monitoring, and strategic program support. The ideal candidate possesses 5+ years of experience in risk adjustment coding or outpatient CDI, CRC certification, and strong communication skills. Homeward offers a competitive salary, equity grant, bonus opportunities, and comprehensive benefits.

Requirements

• Strict adherence to CMS and OIG risk adjustment guidelines, maintaining the highest standards of regulatory compliance and integrity
• 5 years of experience in risk adjustment coding and/or 3 years of outpatient CDI with a strong focus on Medicare Advantage risk adjustment
• Certified Risk Adjustment Coder (CRC) certification
• In-depth knowledge of Medicare Advantage risk adjustment methodology and coding guidelines
• Strong understanding of ICD-10-CM diagnosis coding
• Excellent communication skills
• Familiarity with risk adjustment retrospective chart review coding processes and technology
• Familiarity with electronic health record (EHR) systems
• Knowledge of healthcare compliance, regulations, and billing practices
• Analytical and problem-solving skills

Responsibilities

• Conduct in-depth second-level reviews of outpatient clinical documentation, focusing on identifying and supporting accurate, complete capture of risk-adjustable conditions for Medicare Advantage members
• Lead quality assurance (QA) audits to assess documentation integrity, identify trends in missed opportunities, and ensure coding accuracy
• Champion precise documentation that fully reflects the clinical complexity of Medicare Advantage patients
• Ensure that all active, reportable diagnoses are clearly supported with Diagnosis/Status/Plan (DSP) elements within the encounter—emphasizing the clinical relevance and ongoing management of chronic and complex conditions
• Maintain deep expertise in CMS risk adjustment guidelines, Medicare Advantage policies, and ICD-10-CM coding rules
• Translate these evolving requirements into practical applications for documentation review and improvement, with an eye toward audit preparedness and compliance sustainability
• Deliver timely, actionable feedback and education to providers, grounded in DSP-aligned documentation principles
• Engage in one-on-one coaching, small-group huddles, and educational content development to drive understanding of how accurate documentation impacts patient care quality and risk-adjusted performance
• Ensure coding and documentation practices strictly adhere to Medicare Advantage regulations, including the use of AHIMA/ACDIS-compliant query formats to clarify ambiguous or incomplete documentation
• Monitor for patterns that may indicate compliance concerns—such as unsupported diagnosis coding or inconsistencies—and proactively guide corrective strategies to reduce risk exposure and promote defensible documentation
• Partner in the ongoing development and scaling of Homeward’s outpatient CDI and Coding Support functions
• This includes supporting pre-visit documentation reviews, integrating supplemental data (e.g., health risk assessments), and participating in new initiatives such as HEDIS abstraction, Medicaid CDI pilots, and Commercial risk adjustment reviews

Preferred Qualifications

• Additional AAPC or AHIMA certification (RHIA, RHIT, CDIP, etc.)
• Experience with risk adjustment technology solutions and risk adjustment retrospective chart review vendors
• Previous experience building from the ground up on a small, fast-paced team
• Experience with Medicare Advantage RADV audits

Benefits

• Medical, dental, and vision insurance with 100% of monthly premium covered for employees
• Competitive salary and possible equity grant
• Supplemental performance bonus opportunities
• Relocation and travel reimbursement
• Loan repayment support
• Company-sponsored 401k plan + match
• Generous paid time off
• Comprehensive training provided