Remote Risk Adjustment Coder Jobs in Freeport, NY

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Position Summary
Responsible for managing complex provider-facing workflows, inquiries, and escalations across claims, enrollment, contracting, and regulatory functions. This role serves as a key liaison between providers (including physicians and allied healthcare professionals) and internal operations, leveraging strong analytical capabilities to investigate issues, drive resolution, and ensure compliance with regulatory and network requirements. Position is primarily remote with willingness to travel to office as needed.
Key Role Responsibilities

• Manage complex provider inquiries, escalations, and operational requests across claims, enrollment, and regulatory domains
• Conduct detailed research and analysis of provider disputes, including claims and policy-related issues
• Investigate and respond to executive-level, Department of Insurance (DOI), and medical society complaints
• Research and resolve member or plan sponsor disputes escalated by Sales or Account Management teams
• Facilitate provider termination appeals and incorrect participation corrections
• Coordinate provider contract adjustment requests in partnership with contracting teams
• Support provider enrollment and demographic updates (e.g., TIN changes, address updates, effective dates)
• Escalate and track credentialing and recredentialing issues, including non-responder follow-up
• Facilitate HIPAA-related updates and compliance-related provider requests
• Provide and interpret complete provider participation rosters for large provider groups
• Conduct network directory validation and maintenance activities
• Identify and support resolution of network deficiency gaps, including provider recruitment support
• Assist with fraud, waste, and abuse (FWA) investigations
• Support Medicare eligibility audits, network audits (including Metro NY), and sponsor audit requests
• Participate in quarterly network filing activities and regulatory submissions
• Support chart collection, HEDIS, and Risk Adjustment validation initiatives
• Assist root cause analysis efforts, including roster accuracy and SAI-related clean-up
• Analyze operational data trends to identify process improvement opportunities and recurring issues
• Deliver targeted outreach and follow-up to improve provider compliance and data accuracy
• Educate providers on administrative processes and self-service tools to improve efficiency and accuracy

Required Qualifications

• 2-5 years of professional work experience, 1 year in the healthcare industry
• Experience with medical terminology
• Experience working with Microsoft Office Suite
• Ability to travel in the Metro NY Territory as needed
• Proven ability to manage multiple workflows, prioritize effectively, and meet deadlines
• Strong written and verbal communication skills, with the ability to convey complex information clearly

Preferred Qualifications

• Demonstrated experience working with physicians and other healthcare providers
• Strong analytical and problem-solving skills with the ability to interpret complex data and resolve issues
• Triage member and provider issues (e.g., COB, eligibility, plan setup, pending claims) to appropriate teams to ensure timely resolution
• Build and maintain strong, professional relationships with internal stakeholders and external provider partners
• Perform root cause analysis on recurring provider issues, identifying opportunities for process improvement and policy alignment
• Collaborate cross-functionally to resolve escalated issues impacting providers or operational workflows
• Ensure adherence to contract terms, payment policies, and regulatory requirements
• Engage directly with key providers as needed to support service levels and address concerns

Education

High School Degree or Commensurate Experience

Anticipated Weekly Hours

Time Type

Pay Range

The typical pay range for this role is:

This pay range represents the base hourly rate or base annual full-time salary for all positions in the job grade within which this position falls. The actual base salary offer will depend on a variety of factors including experience, education, geography and other relevant factors. This position is eligible for a CVS Health bonus, commission or short-term incentive program in addition to the base pay range listed above.

Our people fuel our future. Our teams reflect the customers, patients, members and communities we serve and we are committed to fostering a workplace where every colleague feels valued and that they belong.

Great benefits for great people

We take pride in offering a comprehensive and competitive mix of pay and benefits that reflects our commitment to our colleagues and their families.

Additional details about available benefits are provided during the application process and on Benefits Moments.

Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state and local laws.