Role Overview
Help evaluate AI tools that improve risk score accuracy, coding completeness, documentation capture, and risk score integrity across Medicare Advantage, Medicaid managed care, and ACA markets. Your expertise in HCC methodology, risk adjustment coding, and RADV audit preparation will directly inform the development of advanced healthcare AI systems.
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 verify that HCC-eligible conditions are completely and accurately captured and supported by clinical documentation. Conduct and oversee retrospective and prospective chart reviews to optimize risk scores. Manage RADV audit preparation and response activities. Track risk adjustment KPIs, including HCC capture rates, risk score accuracy, and chart retrieval rates. 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, as well as Official Coding Guidelines. Annotate AI outputs and provide structured coding feedback for AI training datasets.
Qualifications
At least 5 years of experience in risk adjustment coding, HCC coding, or Medicare Advantage coding operations, including at least 2 years in a leadership role. Deep knowledge of CMS-HCC, RxHCC, and/or ACA HHS-HCC risk adjustment methodologies. Strong command 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 the ability to identify coding inaccuracies and documentation gaps in AI-generated content.
Preferred Qualifications
CRC, CCS, CPC, or RHIA credential. Experience with risk adjustment analytics platforms and chart retrieval systems. Background in a health plan, Medicare Advantage organization, or value-based care setting. Familiarity with AI-assisted HCC coding tools and evaluating AI-generated risk adjustment content. Experience presenting risk adjustment performance to actuarial or executive teams.
Work Terms
Remote, hourly engagement.
Compensation
$110 per hour.
Opportunity
Contribute to high-impact healthcare AI work, collaborate with an AI research organization, and gain exposure to advanced AI workflows in risk adjustment and value-based care.