Job Description
Risk Adjustment Coder & Auditor (Remote – NY/NJ/CT) Join a growing and highly specialized Risk Adjustment team at a pivotal stage of expansion. We are seeking an experienced Risk Adjustment Coder & Auditor who thrives in a fast-paced, compliance-driven environment and is passionate about coding accuracy, audit readiness, and improving documentation quality. This is an opportunity to become a foundational member of a small, elite team focused on excellence in CMS Risk Adjustment and health plan auditing. Position Summary As a Risk Adjustment Coder & Auditor, you will perform detailed medical record abstraction and coding reviews to ensure accurate ICD-10-CM code assignment for HCC/Risk Adjustment models. You will play a critical role in supporting quarterly RADV audits, validating clinical documentation, and ensuring compliance with CMS and regulatory standards. This role is ideal for a coding professional with deep expertise in health plan operations, audit processes, and risk adjustment methodologies. This is a remote, direct-hire full-time opportunity for candidates residing in New York, New Jersey, or Connecticut. Key Responsibilities Conduct comprehensive medical record reviews and abstraction for accurate HCC/Risk Adjustment coding Assign ICD-10-CM codes in accordance with CMS guidelines and Risk Adjustment models Validate documentation against CMS requirements, including MEAT criteria, provider signatures, dates, and clinical support Support ongoing RADV audit preparation and audit readiness activities occurring quarterly Review coding accuracy from a health plan perspective, ensuring appropriate capture of patient complexity and chronic conditions Identify documentation gaps and collaborate with leadership to support provider education and documentation improvement initiatives Maintain productivity expectations while achieving a minimum 95% coding accuracy standard Assist with quality assurance reviews and compliance monitoring activities Stay current on CMS Risk Adjustment regulations, coding updates, and healthcare compliance standards Required Qualifications Minimum 3–5 years of recent HCC/Risk Adjustment coding experience within a Health Plan, Managed Care, or Auditing environment Dual certification required: One core coding credential: CPC, CCS, RHIT, or RHIA Certified Risk Adjustment Coder (CRC) Strong working knowledge of: ICD-10-CM coding guidelines HCC/Risk Adjustment methodologies Clinical terminology, anatomy, physiology, disease processes, and pharmacology Proven ability to validate documentation for CMS compliance and audit readiness Demonstrated success maintaining a 95% or higher coding accuracy rate Familiarity with claims processing systems and healthcare regulatory requirements Must reside in New York, New Jersey, or Connecticut Dedicated home office with reliable high-speed internet required Preferred Qualifications 8+ years of Risk Adjustment coding and auditing experience Previous experience working directly within a Health Plan or Managed Care Organization Hands-on experience with RADV audits and audit preparation Inpatient coding or auditing background Strong analytical and documentation trend analysis skills Experience providing provider feedback and coding education Knowledge of Medicare Coordination of Benefits (COB) applications and advanced claims systems Why Join Us? Direct-hire full-time opportunity with a growing team Competitive compensation and comprehensive benefits package Robust PTO package plus 10 paid holidays Medical, Dental, and Vision coverage 403(b) Retirement Savings Plan Education reimbursement opportunities Opportunity to make a direct impact on care quality and outcomes for seniors and individuals with chronic conditions throughout the tri-state area