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Nurse Risk Adjustment information

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$38

$65

How much do nurse risk adjustment jobs pay per hour?

As of Jun 29, 2026, the average hourly pay for nurse risk adjustment in the United States is $38.62, according to ZipRecruiter salary data. Most workers in this role earn between $29.57 and $43.27 per hour, depending on experience, location, and employer.

How does a Nurse Risk Adjustment professional typically collaborate with coding and provider teams to ensure accurate risk scoring?

Nurse Risk Adjustment professionals often work closely with medical coders and healthcare providers to review patient documentation and ensure diagnoses are captured accurately for risk adjustment purposes. They may participate in interdisciplinary meetings, provide education to providers on documentation best practices, and clarify coding queries. This collaborative approach helps optimize the accuracy of risk scores, which impacts reimbursement and quality metrics. Effective communication and teamwork are essential in this role to support compliance and achieve organizational goals.

What are nurse risk adjustment nurses?

Nurse risk adjustment nurses are specialized healthcare professionals who review patient medical records to ensure accurate documentation of diagnoses and health conditions. Their work supports the risk adjustment process, which helps health plans and providers receive appropriate compensation based on the health status of their patient populations. These nurses use their clinical expertise to identify missing or undocumented conditions, collaborate with providers to improve documentation accuracy, and help ensure compliance with federal guidelines. By doing so, they play a key role in improving patient care quality and the financial health of healthcare organizations.

What is the difference between Nurse Risk Adjustment vs Nurse Case Manager?

AspectNurse Risk AdjustmentNurse Case Manager
CertificationsRN license, risk adjustment trainingRN license, case management certification
Work EnvironmentInsurance companies, healthcare analyticsHospitals, clinics, patient homes
Employer & IndustryHealth plans, insurance providersHealthcare providers, hospitals

While both roles require RN licensure, Nurse Risk Adjustment focuses on analyzing and coding patient data for insurance risk models, whereas Nurse Case Managers coordinate patient care and manage treatment plans. Understanding these differences helps professionals choose the right career path within healthcare and insurance industries.

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

To thrive as a Nurse Risk Adjustment, you need a solid background in clinical nursing, comprehensive knowledge of medical coding (especially ICD-10), and familiarity with risk adjustment methodologies, typically supported by RN licensure and experience in case management or chart review. Proficiency with electronic health record (EHR) systems, coding software, and sometimes a Certified Risk Adjustment Coder (CRC) credential is valuable. Attention to detail, analytical thinking, and strong communication skills help nurses accurately review documentation and collaborate with providers. These skills ensure accurate coding and risk stratification, which directly impact healthcare reimbursement and quality reporting.
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Nurse Risk Adjustment jobs near you
Infographic showing various Nurse Risk Adjustment job openings in the United States as of June 2026, with employment types broken down into 89% Full Time, 10% Part Time, and 1% Contract. Highlights an 94% Physical, 1% Hybrid, and 5% Remote job distribution, with an average salary of $80,321 per year, or $38.6 per hour.

Manager, Clinical Operations - Risk Adjustment & Quality

Blue Zones Health

La Crescenta, CA • On-site

$100K - $140K/yr

Full-time

Posted 20 hours ago

Job description

Description:

About Blue Zones Health

Blue Zones Health is a lifestyle-first well-being organization that partners with primary care providers and health plans to deliver whole-person care that improves outcomes, reduces unnecessary utilization, and supports patients beyond the four walls of the clinic. Our model integrates lifestyle medicine, health coaching, and social support to address the real drivers of health—especially social, behavioral, and environmental needs.

We work in the real world of healthcare data: eligibility files, claims, enrollment lists, utilization metrics, and financial reporting—often pulled from legacy systems that were never designed for agility. This role exists to both support and modernize this reality.


Position Summary

The Manager, Clinical Operations (Risk Adjustment & Quality) will support the execution and day-to-day management of risk adjustment, coding integrity, and quality improvement initiatives for Blue Zones Health. This role is responsible for coordinating operational activities related to annual wellness visits, coding and documentation accuracy, HEDIS and STARs performance, vendor management, reporting, and quality improvement efforts across multiple health plan partnerships.

The Manager will work closely with internal teams, providers, and external vendors to support operational performance, maintain compliance with regulatory requirements, and drive continuous improvement initiatives.


Key Responsibilities

Risk Adjustment & Coding Support

  • Support the implementation and ongoing management of risk adjustment programs across business lines to promote accurate and compliant coding practices.
  • Coordinate provider coding education initiatives, chart reviews, and audit activities to improve documentation accuracy.
  • Partner with external coding vendors and internal clinical documentation teams to support operational goals and issue resolution.
  • Assist with reconciliation, reporting, and encounter submission processes to identify and address coding gaps.

Quality Program Coordination

  • Support the execution and monitoring of quality improvement initiatives, including HEDIS, STARs, and health plan-specific programs.
  • Coordinate annual wellness visit (AWV) activities, including outreach tracking, scheduling support, completion monitoring, and documentation follow-up.
  • Monitor performance against established quality benchmarks and assist with action plans to improve outcomes.
  • Collaborate with provider groups and internal stakeholders to support quality improvement and member experience initiatives.

Operational Management

  • Maintain operational dashboards, reports, and KPIs to monitor program performance and support accountability.
  • Assist with vendor oversight, including performance tracking, issue escalation, and operational coordination.
  • Partner cross-functionally with Compliance, Finance, Clinical, and Operations teams to support organizational priorities and regulatory requirements.
  • Identify process improvement opportunities and help implement operational efficiencies.

Regulatory & Compliance Support

  • Support compliance with CMS guidelines, DHCS standards, NCQA/HEDIS protocols, Knox-Keene requirements, and other applicable regulations.
  • Participate in internal audit and monitoring activities related to coding, documentation, and quality programs.
  • Maintain current knowledge of risk adjustment, coding, and quality program requirements and best practices.
Requirements:

Qualifications

  • Bachelor’s degree in Nursing, Health Administration, Public Health, or related field required.
  • CPC or CRC certification
  • CPMA or other relevant certification preferred.
  • LVN or RN preferred
  • Minimum 5–7 years of experience in clinical operations, risk adjustment, quality improvement, or managed care operations within a health plan, IPA, or medical group environment.
  • Working knowledge of Medicare Advantage, Medi-Cal, risk adjustment, HEDIS, and STARs programs.
  • Experience coordinating projects, vendors, or operational initiatives in a healthcare environment.
  • Strong analytical, organizational, and problem-solving skills.
  • Excellent communication and collaboration skills with providers, vendors, and internal stakeholders.

Skills & Competencies

  • Strong organizational and project management skills with the ability to manage multiple priorities.
  • Effective communication, facilitation, and relationship-building abilities.
  • Ability to analyze operational data and identify actionable insights.
  • Collaborative mindset with the ability to work across departments and teams.
  • Proficiency in Microsoft Office Suite and project management tools (e.g., Asana, Smartsheet, Trello).
  • Detail-oriented with a proactive and solution-focused approach.