Medicare Risk Adjustment Program Specialist Jobs

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.

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.

• 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.

• 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.