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Remote Risk Adjustment Coding Jobs in Pennsylvania

Corvel

Liability Claims Specialist

Norristown, PA · Remote

$52K - $85K/yr

This is a remote role. Heavy Auto Liability experience is required. ESSENTIAL FUNCTIONS ... The level may impact the salary range and these adjustments would be clarified during the offer ...

Corvel

Liability Claims Specialist

Norristown, PA · Remote

$52K - $85K/yr

This is a remote role. Candidate residing in the Mid-Atlantic Region is preferred. ESSENTIAL ... The level may impact the salary range and these adjustments would be clarified during the offer ...

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Remote Risk Adjustment Coding information

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How much do remote risk adjustment coding jobs pay per hour?

As of Jun 9, 2026, the average hourly pay for remote risk adjustment coding in Pennsylvania is $21.55, according to ZipRecruiter salary data. Most workers in this role earn between $18.08 and $22.88 per hour, depending on experience, location, and employer.

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

To thrive as a Remote Risk Adjustment Coder, you need a solid understanding of medical coding, anatomy, and healthcare regulations, typically backed by a coding certification such as CPC, CRC, or CCS. Familiarity with coding software, electronic health record (EHR) systems, and risk adjustment models like HCC is essential. Attention to detail, critical thinking, and strong written communication are crucial soft skills for interpreting clinical documentation and ensuring coding accuracy. These skills and qualifications are vital to accurately capture patient risk, ensure compliance, and optimize reimbursement for healthcare organizations.

What is remote risk adjustment coding?

Remote risk adjustment coding is the process of reviewing and assigning medical codes to patient diagnoses and procedures from a remote location, usually at home. The purpose is to ensure that healthcare organizations accurately report the health status of their patients, which affects reimbursement from health plans. Coders use specialized knowledge of ICD-10-CM coding and risk adjustment models, such as HCC (Hierarchical Condition Category) coding, to capture all relevant chronic conditions. This position requires attention to detail, compliance with regulations, and strong analytical skills.

What is the difference between Remote Risk Adjustment Coding vs Remote Medical Coding?

AspectRemote Risk Adjustment CodingRemote Medical Coding
CertificationsRHIA, RHIT, CPC, CCSCPC, CCS, CCS-P
Work EnvironmentHealthcare organizations, insurance companiesHospitals, clinics, insurance companies
Industry UsageHealth insurance, risk adjustment programsMedical billing, claims processing

Remote Risk Adjustment Coding focuses on analyzing patient data for insurance risk assessments, requiring specific risk adjustment certifications. Remote Medical Coding involves coding diagnoses and procedures for billing purposes. While both roles require coding certifications, Risk Adjustment Coding emphasizes risk analysis within insurance, whereas Medical Coding centers on billing accuracy.

How does working remotely as a Risk Adjustment Coder impact collaboration with healthcare teams and ongoing professional development?

As a remote Risk Adjustment Coder, you'll often collaborate with clinical staff, auditors, and other coders through secure digital platforms and regular virtual meetings. While remote work offers flexibility, it also means that proactive communication is essential to ensure accurate coding and compliance with regulations. Many organizations provide virtual training sessions, access to coding forums, and ongoing education to help you stay updated on industry changes and coding standards. Building relationships with your team and participating in online professional communities can further support your growth and help overcome the isolation that sometimes comes with remote work.
What are popular job titles related to Remote Risk Adjustment Coding jobs in Pennsylvania? For Remote Risk Adjustment Coding jobs in Pennsylvania, the most frequently searched job titles are:
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What cities in Pennsylvania are hiring for Remote Risk Adjustment Coding jobs? Cities in Pennsylvania with the most Remote Risk Adjustment Coding job openings:
Remote Risk Adjustment Coding jobs near you
Infographic showing various Remote Risk Adjustment Coding job openings in Pennsylvania as of June 2026, with employment types broken down into 86% Full Time, 12% Part Time, and 2% Contract. Highlights an 76% Physical, 7% Hybrid, and 17% Remote job distribution, with an average salary of $44,831 per year, or $21.6 per hour.

Clinical Auditor/Analyst (Remote)- Fraud, Waste and Abuse

UPMC Senior Communities

Pittsburgh, PA • On-site, Remote

$32.85 - $56.83/hr

Full-time

Posted 6 days ago

Job description

UPMC Health Plan has an exciting opportunity for a Clinical Auditor/Analyst position in the Fraud, Waste & Abuse department. This is a full time position working Monday through Friday daylight hours and will be a remote position.
The Clinical Auditor/Analyst is an integral part of the Special Investigations Unit (SIU) and is responsible for conducting clinical audits and reviews regarding the analysis of care and services related to clinical guidelines, coding requirements, regulatory requirements, and resource utilization. The Clinical Auditor/Analyst creates, maintains and analyzes auditing reports related to their assigned work plan and communicates the results with management. Other responsibilities include but are not limited to analysis of controlled substance prescribing and utilization to identify potential clinical care issues, prepayment review of claims, and prepayment review of unlisted codes. Claims analysis and the use of fraud and abuse detection software tools will be an integral part of the function of this position. Responsibilities will involve working in collaboration with appropriate Health Plan departments including Quality Improvement, Legal, and Medical Management to facilitate the resolution of issue or cases. Responsibilities may involve multiple line of business focused reviews, or ad hoc reviews as needed; analysis of billing by providers/physicians, and providing trending, analysis and reporting of auditing data. The Clinical Auditor/Analyst will routinely interact with providers, law enforcement and/or regulatory entities in the course of their duties.
Experience in mental health claims review and laboratory claims review is highly preferred!
Responsibilities:
  • Respond to fraud, waste, and abuse referrals and/or complete data analysis and related audits as assigned.
  • Utilize fraud detection software to assess and monitor for potential FWA.
  • Review and analyze claims, medical records and associated processes related to the appropriateness of coding, clinical care, documentation, and health plan business rules.
  • Provide a clinical opinion for special projects or various issues including appropriate utilization of controlled substances, prescribing of controlled substances, or medically appropriate services.
  • Query medical and/or pharmacy claims and conduct a risk assessment by performing data analysis and applying applicable coding guidelines,
  • Health Plan policies and any applicable National Coverage Determination (NCD) or Local Coverage Determination (LCD).Evaluate referrals from Pharmacy Benefit Manager (PBM) by analyzing medical and pharmacy claims and associated clinical documentation in HealthPlaNET, Mars, Epic and/or Cerner.
  • Complete audits by utilizing standard coding guidelines and principles and coding clinics to verify that the appropriate CPT codes/DRGs were assigned and supported in the medical record documentation.
  • Attend in person or virtual recipient restriction hearings.
  • Review Medical Pended Queue claims to understand and resolve claim referral issues through research and interaction with other Health Plan Departments including Medical Management, Medical Directors, various committees, and other appropriate Health Plan departments.
  • As necessary, assist in the development of new policies concerning future Health Plan payment of identified issue.
  • Assess, investigate and resolve low to intermediate issues.
  • Write concise written reports including statistical data for communication to other areas of UPMC Health Plan and to communicate with department heads for identification of various problem issues, how they affect the Health Plan, and to make recommendations for resolution of the issue.
  • Identify error trends to determine appropriate training needs and suggest modifications to company policies and procedures.
  • Conduct provider education, as necessary, regarding audit results.
  • Communicate effectively with Medical Directors and ancillary departments as necessary to address issues and concerns.
  • Understand customers including internal Health Plan Departments (i.e. Claims staff, Customer Service, Marketing, etc.) and external customers (i.e. Health System Internal Audit, Client Audit teams) to understand issues, identify solutions and facilitate resolution.
  • Serve as an SIU representative at internal and external meetings, document and present findings to SIU Staff and document as appropriate in the SIU FWA Case Management Database.
  • Assist in the development and revision of SIU policies and procedures.
  • Identify trends for improvements internally, such as claims payment, to determine appropriate training needs and suggest modification to company policies and procedures.
  • Participate in training programs to develop a thorough understanding of the materials presented.
  • Obtain CPE or CEUs to maintain nursing license, and/or professional designations.
  • Design and maintain reports, auditing tools and related documentation.
  • Maintain or exceed designated quality and production goals.
  • Maintain employee/insured confidentiality and adhere to HIPAA regulations.

Qualifications:
  • Registered Nurse (RN).
  • Five years of clinical experience.
  • Two years of fraud & abuse, auditing, case management, quality review or chart auditing experience required.
  • Ability to analyze data, maintain designated production standards, and organize multiple projects and tasks.
  • In-depth knowledge of medical terminology, ICD-10 and CPT-4 coding. Knowledge of health insurance products and various lines of business.
  • Detail-oriented individual with excellent organizational skills.
  • Keyboard dexterity and accuracy.
  • High level of oral and written communication skills.
  • Proficiency with Microsoft Office products (Excel, Access, OneDrive, OneNote and Word).
    Licensure, Certifications, and Clearances:
    AAPC or AHIMA Certified (CPC, CPMA, CIC, CCA, CCS, CCS-P) or AHFI designation preferred.
  • Registered Nurse (RN)

*Current licensure either in the state where the facility is located or, if the facility is in a state covered by the multistate Nursing Licensure Compact (NLC) agreement, a multistate license issued by a participating NLC state. Hires and current employees working on an out-of-state NLC license who later change their residency to the state where the facility is also located will have 60 days upon changing their residency to apply for licensure within that state.
UPMC is an Equal Opportunity Employer/Disability/Veteran

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