Risk Adjustment Quality Assurance (QA) Reviewer

Job Description Summary

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Serves as the most advanced operational resource within the Risk Adjustment Coding function, providing expert-level coding support, process leadership, and guidance to coding staff. Applies extensive knowledge of Medicare risk adjustment methodologies, HCC coding, ICD-10-CM guidelines, and documentation requirements to resolve the most complex coding and documentation issues. Functions as the primary escalation resource for coding questions, operational challenges, and quality concerns while supporting consistency across coding activities.

Works with minimal supervision and is recognized as a specialist within the department. Owns key coding processes and operational workflows, recommends process improvements, and serves as an indirect team lead by providing training, work direction, coaching, and quality review support to other coding staff without formal supervisory responsibility. Decisions impact departmental performance, coding quality, documentation integrity, and operational effectiveness.

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How will you make an impact & Requirements

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Key Responsibilities • Serve as the primary escalation resource for complex coding, documentation, compliance, and risk adjustment questions requiring advanced interpretation of coding guidance and regulatory requirements. • Perform advanced reviews of medical records to validate diagnosis coding accuracy, documentation support, and appropriate HCC capture in accordance with CMS and organizational standards. • Lead resolution of non-routine coding issues and operational challenges by researching regulatory guidance, analyzing documentation, and recommending appropriate coding outcomes. • Act as an indirect team lead by providing day-to-day guidance, training, work direction, and knowledge sharing to coding staff while supporting consistency across coding activities. • Review coding work, provide coaching and feedback, and assist with onboarding and development of new team members. • Own and support designated coding processes, workflows, tools, or operational initiatives and recommend improvements that enhance coding quality, productivity, and compliance. • Analyze coding, documentation, and provider trends to identify opportunities for improved diagnosis capture, documentation integrity, and operational performance. • Develop and maintain coding resources, job aids, reference materials, and process documentation that support standardization across the function. • Support audits, quality reviews, validation activities, and regulatory readiness initiatives. • Participate in departmental projects and cross-functional initiatives supporting value-based care performance, coding accuracy, and risk adjustment outcomes. • Maintain established productivity, quality, and compliance standards while managing advanced coding assignments independently.

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Compensation Range:

$27.82

to

$41.72

 

The anticipated base salary range represents the Company's good-faith estimate of the compensation it reasonably expects to pay for this position at the time of posting. Actual compensation will be determined based on factors including experience, skills, qualifications, geographic location, internal equity, and business needs.