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Medicare Risk Adjustment Jobs (NOW HIRING)

Molina Healthcare

VP, Risk Adjustment

Long Beach, CA · On-site +1

$137K - $184K/yr

Provides executive oversight of all risk adjustment programs across Medicare Advantage, Medicaid, and ACA Marketplace lines of business, ensuring alignment of operational activities with ...

Oscar Health

Auditor, Risk Adjustment

Miami, FL · Remote

$82K - $108K/yr

We're hiring a Associate, Risk Adjustment Auditor to join our Risk Adjustment team. Oscar is the ... Medicare & Medicaid Services (CMS), Health and Human Services (HHS) audits and medical record ...

Vertek Staffing

HCC Risk Adjustment Coder

Franklin, TN · Remote

$18 - $24/hr

HCC / Risk Adjustment Coder - Remote Risk Adjustment / HCC Coding Experience Required Required ... Experience with Medicare Advantage populations * Experience with value-based care programs

Strive Health

Risk Adjustment Coder

Denver, CO · Remote

$27.88 - $32.21/hr

What You'll Do The Coder, Risk Adjustment Coding is responsible for supporting the Strive ... Extensive knowledge of documentation and coding guidelines established by the Center for Medicare ...

Strive Health

Risk Adjustment Coder

Denver, CO · On-site +1

$19.25 - $25.75/hr

What You'll Do The Coder, Risk Adjustment Coding is responsible for supporting the Strive ... Extensive knowledge of documentation and coding guidelines established by the Center for Medicare ...

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Medicare Risk Adjustment information

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How much do medicare risk adjustment jobs pay per hour?

As of Jul 2, 2026, the average hourly pay for medicare risk adjustment in the United States is $22.42, according to ZipRecruiter salary data. Most workers in this role earn between $16.11 and $27.16 per hour, depending on experience, location, and employer.

What Are Jobs in Medicare Risk Adjustment?

Jobs in Medicare risk adjustment include work in data analytics, consulting, insurance, and closely related industries. Your duties and responsibilities differ depending on the type of work. For example, as a Medicare risk-adjustment consultant, you provide advice and recommendations to healthcare organizations or an insurance provider on how to mitigate risk across a customer pool. Data analytics and statistics specialists gather and analyze insurance and Medicare data and documentation from hospitals, healthcare providers, and other medical care facilities that accept Medicare. This includes reviewing different types of diagnosis and comparing patient chart information. Some health care providers have in-house risk adjustment workers, while others contract with outside consulting and analytics firms.

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

AspectMedicare Risk AdjustmentMedicare Coding Specialist
Primary FocusAssessing patient health risk scores for reimbursementAccurately coding medical diagnoses and procedures
Required CredentialsCertifications in risk adjustment or coding, often CPC or RHITCertifications like CPC, CCS, or RHIT
Work EnvironmentHealth plans, risk adjustment companies, healthcare providersHospitals, clinics, billing departments
Industry UsageUsed for Medicare Advantage plan reimbursementsUsed for medical billing and claims processing

While both roles involve healthcare coding and require similar certifications, Medicare Risk Adjustment focuses on evaluating patient health data to determine reimbursement levels, whereas Medicare Coding Specialists concentrate on accurately coding diagnoses and procedures for billing purposes.

What is Medicare Risk Adjustment?

Medicare Risk Adjustment is a process used by the Centers for Medicare & Medicaid Services (CMS) to adjust payments to Medicare Advantage plans based on the health status and demographic characteristics of their enrolled beneficiaries. The goal is to ensure that plans receive appropriate compensation for taking care of members with varying levels of health risk. This system uses diagnosis codes and other data to predict future healthcare costs, encouraging plans to provide comprehensive care and accurately document patient conditions.

What are some common challenges faced by professionals working in Medicare Risk Adjustment roles?

Professionals in Medicare Risk Adjustment often encounter challenges such as staying current with frequently changing CMS regulations, ensuring the accurate capture and documentation of patient diagnoses, and collaborating effectively with providers to optimize risk scores. The role requires meticulous attention to detail when reviewing medical records and coding, as well as strong communication skills to educate and support healthcare teams. Additionally, there can be pressure to meet strict deadlines for data submission and to ensure compliance with audit standards.

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

To excel in Medicare Risk Adjustment, you need a solid understanding of medical coding (especially ICD-10), healthcare regulations, and risk adjustment methodologies, often supported by credentials like CRC or CPC certifications. Familiarity with data analytics platforms, EHR systems, and specialized risk adjustment software is typically required. Strong attention to detail, analytical thinking, and effective communication are crucial soft skills for interpreting complex clinical data and collaborating across teams. These competencies ensure accurate risk scores, compliance with CMS requirements, and optimal financial outcomes for healthcare organizations.
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Medicare Risk Adjustment jobs near you
Informatics Risk Adjustment Consultant

Informatics Risk Adjustment Consultant

HealthPartners

Saint Paul, MN

Other

Medical, Retirement

Posted 23 days ago

HealthPartners rating

7.7

Company rating: 7.7 out of 10

Based on 132 frontline employees who took The Breakroom Quiz

160th of 877 rated healthcare providers

Job description

HealthPartners is hiring a Informatics Risk Adjustment Consultant.  The Informatics Consultant -supports the Health Plan's risk adjustment operations by delivering trusted, prioritized, and compliant data insights that drive efficient workflows and improve risk score accuracy, while continuously refining processes through feedback. This role ensures the plan's risk adjustment outputs are accurately represented in claims and encounter data, analytics, and reporting.

The consultant serves as a bridge between the data/technology teams and risk adjustment operations, clinical/provider stakeholders, coding and chart review teams, and compliance/audit partners. The role enables informed, compliant, and actionable risk adjustment program, while maintaining strong governance, audit readiness, and organizational standards.

ACCOUNTABILITIES:  

Risk Adjustment Strategy & Program Execution

  • Support planning and execution of annual risk adjustment initiatives (prospective, concurrent, and retrospective), aligned to plan goals and regulatory requirements.
  • Translate risk adjustment priorities into practical workflows, playbooks, and measurable interventions across provider groups and vendor partners.
  • Partner with risk adjustment operations to optimize data capture, risk score modeling, member stratifications, suspecting logic, and program outcomes.

Diagnosis Accuracy, Clinical Validity & Documentation Integrity

  •  
  • Identify patterns of under-capture, over-capture, and potential diagnosis coding inaccuracies; drive suspecting logic and workflow improvements.
  • Support provider-facing reporting 

Encounter & Claims Data Quality (Core Health Plan Focus)

  • Work with operational and technical teams to improve completeness, timeliness, and accuracy of encounter data and diagnosis submission (including resolving rejections, edit failures, and submission gaps).
  • Define and monitor data quality KPIs (e.g., encounter internal validations, submission rates, acceptance rates, diagnosis completeness, provider group variation, lag time).

Provider & Vendor Enablement (External-Facing Consulting)

  • Support relationships with provider groups, delegated entities, and vendor partners to improve data exchange and workflows
  • Participate in vendor management activities (requirements gathering, performance monitoring, issue escalation, and continuous improvement).

Measurement, Analytics & Performance Reporting

  • Define and track risk adjustment performance measures such as:
    • Reconfirmation rates and suspected-condition confirmation rates
    • Member visit rates and provider engagement
    • Condition prevalence shifts and variation analysis
    • Net risk score movement (where appropriate) with integrity guardrails, and drivers of risk
    • Encounter submission acceptance rates 
    • Audit results and feedback loop reporting
  • Partner with analytics teams to develop dashboards and actionable reporting (e.g., Power BI), and to ensure consistent measure definitions.

Compliance, Audit Readiness & Governance

  • Partner with compliance, internal audit, and risk adjustment leadership to support audit readiness (e.g., documentation standards, monitoring, validation processes).
  • Help implement controls and monitoring to identify outliers and reduce risk (e.g., unusual provider patterns, unsupported diagnoses, excessive suspecting false positives).
  • Maintain familiarity with current risk adjustment policies and guidance, and support operational implementation of updates.

Cross-Functional Leadership & Change Management

  • Facilitate collaboration between data/technology teams and risk adjustment operations, clinical/provider stakeholders, coding and chart review teams, and compliance/audit partners.

  • When asked, co-lead small to medium initiatives end-to-end, including requirements definition, workflow design, stakeholder engagement, training, measurement, and sustainment.

    REQUIRED QUALIFICATIONS:  

1. Education

  • Bachelor's degree in health informatics, nursing, health information management, public health, business, or related field; or equivalent combination of education and experience.

2. Experience and Knowledge

  • 5+ years of experience in health plan and/or risk adjustment-related domains, such as: risk adjustment operations, encounter data management, coding, clinical documentation integrity, provider performance, quality improvement, or healthcare analytics.
  • Working knowledge of how diagnoses flow through EHR coding/chart review encounter/claims submission risk adjustment analytics.
  • Experience collaborating with provider organizations and/or delegated entities to improve documentation and data submission practices.
  • Experience using data to drive improvement: ability to interpret trends, variation, root cause issues, and performance metrics.
  • Familiarity with Medicare Advantage (preferred) and/or other risk programs, including chart review concepts and audit sensitivity.

3. Skills

  • Strong consulting, facilitation, and stakeholder management skills; able to influence without authority.
  • Excellent written and verbal communication; able to create clear playbooks, training, and executive-ready summaries.
  • Strong analytical thinking and operational problem-solving; comfortable navigating ambiguous issues across workflows and systems.
  • High integrity and sound judgment; commitment to compliant, clinically appropriate documentation practices.
  • Strong project management skills; ability to manage multiple workstreams, deadlines, and cross-functional dependencies.

PREFERRED QUALIFICATIONS:

  • Credentials such as CRC, CPC, CCS, CDIP, CCDS (or comparable).
  • Experience working directly with MA encounter submission processes, edit resolution, or encounter data ingestion/validation.
  • Experience supporting chart retrieval/coding vendors and performance management (KPIs, SLAs, escalation paths).
  • Familiarity with audit processes and documentation standards (e.g., retrospective validation, risk adjustment audits), and designing monitoring/controls.
  • Experience developing or specifying requirements for dashboards and operational reporting (Power BI, Tableau, or equivalent).
  • Solid working experience with SQL and relational database design
  • Exposure to agile/scrum
  • Experience using Azure suite of tools, Databricks, Azure Data Lake
  • Experience in a highly regulated environment and comfort partnering closely with compliance and privacy.

At HealthPartners we believe in the power of good - good deeds and good people working together. As part of our team, you'll find an inclusive environment that encourages new ways of thinking, celebrates differences, and recognizes hard work.

We're a nonprofit, integrated health care organization, providing health insurance in six states and high-quality care at more than 90 locations, including hospitals and clinics in Minnesota and Wisconsin. We bring together research and education through HealthPartners Institute, training medical professionals across the region and conducting innovative research that improve lives around the world.

At HealthPartners, everyone is welcome, included and valued. We're working together to increase diversity and inclusion in our workplace, advance health equity in care and coverage, and partner with the community as advocates for change.

Benefits Designed to Support Your Total Health
As a HealthPartners colleague, we're committed to nurturing your diverse talents, valuing your dedication, and supporting your work-life balance. We offer a comprehensive range of benefits to support every aspect of your life, including health, time off, retirement planning, and continuous learning opportunities. Our goal is to help you thrive physically, mentally, emotionally, and financially, so you can continue delivering exceptional care.

Join us in our mission to improve the health and well-being of our patients, members, and communities.

We are an Equal Opportunity Employer and do not discriminate against any employee or applicant because of race, color, sex, age, national origin, religion, sexual orientation, gender identify, status as a veteran and basis of disability or any other federal, state or local protected class.

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