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Medicare Risk Adjustment Audit Jobs in Texas (NOW HIRING)

Harris Health System

Risk Adjustment Coder II

Houston, TX · On-site

$27.69 - $34.61/hr

Community Health Choice (HMO D-SNP), a Medicare Advantage Dual Special Needs plan for people with ... assurance audits, and collaborating with multiple departments across the organization. JOB ...

Harris Health System

Risk Adjustment Coder II

Houston, TX · On-site

$27.69 - $34.61/hr

... Medicare and Medicaid that combines Medicare Part A and Part B benefits, Medicare Part D ... assurance audits, and collaborating with multiple departments across the organization. JOB ...

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Medicare Risk Adjustment Audit information

What is a Medicare Risk Adjustment Audit?

A Medicare Risk Adjustment Audit is a review process conducted to ensure that healthcare providers are accurately reporting patient diagnoses to Medicare Advantage plans. This audit verifies that submitted diagnoses are supported by proper medical documentation, which affects how much Medicare pays to health plans. The goal is to prevent overpayments or underpayments and to ensure compliance with federal regulations. These audits are typically performed by the Centers for Medicare & Medicaid Services (CMS) or their contractors.

What are some common challenges faced by professionals in Medicare Risk Adjustment Audit roles, and how can they be addressed?

Professionals in Medicare Risk Adjustment Audit roles often encounter challenges such as interpreting complex medical documentation, staying updated on evolving CMS guidelines, and ensuring data accuracy for compliant risk scoring. Effective collaboration with coders, providers, and compliance teams is essential to resolve discrepancies and achieve audit objectives. Staying proactive in ongoing training and leveraging audit technologies can help address these challenges and contribute to high-quality, compliant results.

What are the key skills and qualifications needed to thrive as a Medicare Risk Adjustment Auditor, and why are they important?

To thrive as a Medicare Risk Adjustment Auditor, you need expertise in medical coding, healthcare compliance, and an understanding of CMS risk adjustment guidelines, often supported by a coding certification such as CPC or CRC. Familiarity with auditing software, electronic health records (EHRs), and data analytics tools is typically required. Attention to detail, analytical thinking, and strong communication are essential soft skills for reviewing documentation and conveying findings. These skills are crucial for ensuring accurate risk adjustment coding, regulatory compliance, and optimized reimbursement for healthcare organizations.

What is the difference between Medicare Risk Adjustment Audit vs Medicare Coding Specialist?

AspectMedicare Risk Adjustment AuditMedicare Coding Specialist
Primary FocusReviewing and verifying accuracy of risk adjustment dataAssigning correct medical codes for billing and documentation
CertificationsRisk adjustment or auditing certifications often preferredMedical coding certifications like CPC or CCS
Work EnvironmentHealthcare organizations, insurance companies, auditing firmsHospitals, clinics, billing companies
Industry UsageUsed in Medicare Advantage plan compliance and reimbursementUsed in medical billing and claims processing

While both roles involve healthcare data, Medicare Risk Adjustment Auditors focus on verifying the accuracy of risk scores for Medicare payments, whereas Medicare Coding Specialists assign medical codes for billing purposes. Understanding these differences helps in choosing the right career path or job focus within the healthcare industry.

What are popular job titles related to Medicare Risk Adjustment Audit jobs in Texas?

For Medicare Risk Adjustment Audit jobs in Texas, the most frequently searched job titles are:

What job categories do people searching Medicare Risk Adjustment Audit jobs in Texas look for?

The top searched job categories for Medicare Risk Adjustment Audit jobs in Texas are:

What cities in Texas are hiring for Medicare Risk Adjustment Audit jobs?

Cities in Texas with the most Medicare Risk Adjustment Audit job openings:

Medicare Risk Adjustment Audit jobs near you
Infographic showing various Medicare Risk Adjustment Audit job openings in Texas as of August 2026, with employment types broken down into 1% As Needed, 87% Full Time, 10% Part Time, and 2% Contract. Highlights an 88% Physical, 3% Hybrid, and 9% Remote job distribution.

Risk Adjustment Coder II

Community Health Choice, Inc.

Houston, TX • On-site

$60 - $80/hr

Other

Medical, Dental, Vision

Posted 5 days ago

Community Health Choice rating

8.7

Company rating: 8.7 out of 10

Based on 6 frontline employees who took The Breakroom Quiz

72nd of 315 rated insurance

Job description

Company Overview

Community Health Choice, Inc. (Community) is a non‑profit managed care organization (MCO), licensed by the Texas Department of Insurance. Through its network of more than 10,000 providers and 94 hospitals, Community serves over 400,000 members with the following programs:

  • Medicaid State of Texas Access Reform (STAR) program for low‑income children and pregnant women
  • Children's Health Insurance Program (CHIP) for the children of low‑income parents, which includes CHIP Perinatal benefits for unborn children of pregnant women who do not qualify for Medicaid STAR
  • Health Insurance Marketplace Plans that offer individual health coverage that includes preventive care, emergency services, prescription drugs, and hospitalization available to all, regardless of pre‑existing conditions.
  • Community Health Choice (HMO D‑SNP), a Medicare Advantage Dual Special Needs plan for people with both Medicare and Medicaid that combines Medicare Part A and Part B benefits, Medicare Part D prescription drug coverage, and Medicaid benefits with additional health benefits like dental, vision, transportation, and more.

Improving Members' experiences is at the heart of every Community position. We strive every day to make sure that our Members have access to the high‑quality health care they need and deserve.

Community is accredited by URAC for its health plan operations. We offer care management programs for asthma, diabetes, and high‑risk pregnancy. An affiliate of the Harris Health System (Harris Health), Community is financially self‑sufficient and receives no financial support from Harris Health or from Harris County taxpayers.

Job Summary

The Risk Adjustment Coder II provides advanced support for complex medical record reviews to ensure the correct capture of chronic conditions and complexities to calculate a patient's risk score, by mapping diagnoses to Hierarchical Condition Categories (HCCs) while adhering to CMS guidelines and internal coding policies for the following programs: including, but not limited to, Commercial Risk Adjustment, Medicare Risk Adjustment, and HHS and Medicare RADV (Risk Adjustment Data Validation). The Risk Adjustment Coder II will serve as a subject‑matter expert for risk adjustment and will assist in the development of team trainings, quality assurance audits, and collaborating with multiple departments across the organization.

Job Specifications and Core Competencies
  • Provide advanced complex medical records reviews to identify and code all relevant diagnoses, including chronic conditions, utilizing ICD‑10 coding guidelines for Commercial and Medicare risk adjustment programs.
  • Conduct thorough clinical documentation review to ensure sufficient support and management for coded conditions.
  • Identify opportunities to improve documentation and coding accuracy; provide analysis and recommendations for improvement to leadership.
  • Consistently meet productivity and quality standards as outlined by supervisor.
  • Ensure coding compliance by following the Official Coding Guidelines, HHS‑RADV Protocols, and attending REGTAP calls.
  • Stay current with coding standards, risk adjustment methodologies, and CMS regulatory changes to ensure ongoing compliance and optimal coding practices.
  • Actively contributes to achievement of departmental goals, as identified in Department's annual business plan, including specific departmental process improvement plans, and other duties as assigned.
Qualifications
  • Education/Specialized Training/Licensure: Bachelor's Degree or 5 or more years of experience in risk adjustment in lieu of degree required.
  • AHIMA/AAPC Certified Coder, Medical Billing and Coding certification required (CPC, CRC, COC, CCS, CCS‑P, or any combination of listed certifications).
  • Associate or bachelor's degree preferred.
  • Work Experience: 3‑5 years' experience in Commercial or Medicare risk adjustment coding required.
  • Clinical documentation improvement experience for inpatient and outpatient preferred.
  • Experience within a managed care organization preferred.
  • Management Experience: N/A (Some management experience preferred).
  • Software Proficiencies: Microsoft 365 (Word, Excel, Outlook, SharePoint, Teams).
  • Other: Strong analytical skills, strong written and verbal skills, strong interpersonal skills, solid knowledge of ACA, Medicaid, and Medicare Risk Adjustment.
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