Risk Adjustment Compliance Coder
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AI Summary
The role focuses on enhancing the accuracy and integrity of coding data for Medicare and Medicaid reimbursement through audits and compliance research. It involves collaborating with providers to improve diagnosis capture and delivering educational guidance on risk adjustment guidelines.
DATE: June 4, 2026
POSITION: Risk Adjustment Compliance Coder
DEPARTMENT: Finance-Risk Adjustment
RATE: $28.86 per hour, with potential for additional compensation based on qualifications.
POSITION SUMMARY:
The Risk Adjustment Compliance Coder is responsible for enhancing the accuracy, quality, and integrity of coding data that supports Medicare and Medicaid reimbursement. This role conducts risk adjustment coding audits, performs compliance research, responds to coding inquiries, and serves as a subject matter expert in risk adjustment coding and compliance. The position supports Medicare and Medicaid risk adjustment programs through the development, implementation, and ongoing evaluation of program initiatives. Highly collaborative and operational in nature, this role partners closely with providers and internal stakeholders and requires strong communication, education, and relationship-management skills. This is not a traditional production-focused coding position.
ESSENTIAL DUTIES AND RESPONSIBILITIES:
1. Follows established Upper Peninsula Health Plan (UPHP) policies and procedures, objectives, safety standards, and sensitivity to confidential information.
2. Collaborates with Risk Adjustment Analyst to develop, implement, and continually refine internal prospective and retrospective chart review programs and related risk adjustment initiatives.
3. Follows International Classification of Diseases (ICD)-10 guidelines for Coding and Reporting, Centers for Medicare & Medicaid Services (CMS) risk adjustment guidelines, and demonstrates knowledge of Current Procedural Terminology (CPT) coding. Understands the impact of ICD-10 coding on the CMS Hierarchical Condition Categories (HCC) risk adjustment model, and serves as the subject matter expert for risk adjustment activities.
4. Supports risk adjustment compliance and program integrity activities, including RADV preparedness, high-risk diagnosis review and validation, audit support, and identification and escalation of potential coding or documentation compliance concerns.
5. Assists with extraction of charts via remote Electronic Medical Record (EMR) access or faxed medical record request for risk adjustment initiatives.
6. Performs comprehensive medical record review, verifying and ensuring accuracy, completeness, specificity, and appropriateness of diagnoses codes in accordance with ICD-10 guidelines based on medical record documentation. Documents trends, observations, and potential coding or documentation improvement opportunities identified during the review process.
7. Maintains a comprehensive tracking and management tool to track all coding activities; generates and maintains accurate weekly, monthly, and quarterly reports of activities.
8. Assists with chart review encounter data submissions to CMS based on chart review findings.
9. Provides support during the annual retrospective chart review performed by an external party.
10. Identifies, develops, and delivers general and specific educational guidance to providers and clinic staff through webinars, newsletters, presentations, and other educational forums based on risk adjustment audit findings, CMS guidelines, regulatory requirements, and industry best practices.
11. Collaborates with internal departments, as appropriate, to carry out risk adjustment program activities to ensure integrity of diagnoses attributed to members submitted to the Michigan Department of Health and Human Services (MDHHS) and CMS by UPHP.
12. Collaborates with healthcare leaders, physicians, and provider office personnel to improve the accuracy and completeness of diagnosis code capture. Facilitates provider education, documentation clarification, and coding-related discussions in a professional, consultative manner to support risk adjustment and compliance objectives.
13. Maintains confidentiality of client data.
14. Performs other related duties as assigned or requested.
POSITION QUALIFICATIONS:
Education:
Minimum:
High School Diploma
Preferred:
Associate degree in business, health information processing, or related field
Certification:
Minimum:
Must possess and maintain an American Academy of Professional Coders (AAPC) or American Health Information Management Association (AHIMA) certification—Certified Coding Specialist (CCS), Certified Coding Specialist-Physician (CCS-P), Certified Professional Coder (CPC), or Certified Risk Adjustment Coder (CRC)
Preferred:
Certified Coding Specialist (CCS-P, CCS, CPC) and Certified Risk Adjustment Coder (CRC)
Experience:
Minimum:
Two (2) years of experience in medical chart coding
Preferred:
Five (5) years of experience in medical chart coding, including inpatient and outpatient settings; working knowledge of managed care and health plan standards on Risk Adjustment Coding
Other Qualifications:
Knowledge and understanding of medical terminology, disease process, and anatomy and physiology
Advanced knowledge and understanding of CPT coding across a wide variety of provider specialties
Required Skills:
Excellent organizational abilities with attention to detail
Ability to effectively communicate with, and educate, clinic staff (provider, care managers, clinic quality leads, etc.)
Working knowledge of Microsoft Office (Word, Excel, Outlook)
Keyboarding proficiency
Research and analytical skills
Preferred Skills:
Knowledge of MS PowerPoint
Oriented to managed care
The qualifications listed above are intended to represent the minimum skills and experience levels associated with performing the duties and responsibilities contained in this job description. The qualifications should not be viewed as expressing absolute employment or promotional standards, but as general guidelines that should be considered along with other job-related selection or promotional criteria.
Physical Requirements:
[This job requires the ability to perform the essential functions contained in the description. These include, but are not limited to, the following requirements. Reasonable accommodations may be made for otherwise qualified applicants unable to fulfill one or more of these requirements]:
Ability to enter and access information from a computer
Occasionally lifts supplies/equipment
Prolonged periods of sitting
Manual dexterity
Working Conditions:
Position available onsite (in Marquette, Michigan), fully remote, or hybrid with a remote work option up to three (3) days per week
Works in office conditions, but occasional travel is required
Exposure to situations requiring exceptional interpersonal skills or high productivity
Occasionally subjected to irregular hours
Subject to many interruptions
Remote Work Requirements:
Remote candidates must reside in the state of Michigan
For fully remote team members, initial on-site/in-person onboarding and training for a minimum of ten (10) consecutive business days at UPHP’s headquarters in Marquette, Michigan (stipend provided)
Periodic travel to UPHP’s headquarters for regular training including all staff meetings
Private home office required; computer and phone hardware provided
Personal vehicle required for periodic travel; mileage reimbursement provided at GSA rate
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