Senior Analyst, Risk Adjustment Strategy

What You'll Do

• Author, refine, and govern the risk adjustment coding and documentation standards. The working copy of the single source of truth that internal coders, CDI reviewers, and provider education follow across all IPAs managed by the company
• Translate risk adjustment model specifications and payer requirements into clear, enforceable coding rules, and keep those rules current as models and guidance change
• Define encounter and source-of-truth rules i.e. which encounter types, provider types, settings, and data sources support a risk-adjustable diagnosis and which do not, documenting the regulatory basis for each
• Set MEAT/TAMPER documentation criteria by condition category, compliant query rules, and an adjudication path with a versioned decision log, so ambiguous cases are resolved the same way by every coder in every market
• Establish program guardrails that produce accurate capture not upcoding. This includes chart review scope rules and deletion obligations when review surfaces unsupported codes
• Own audit defense, chart standards written backwards from the audit, sampling and validation logic, and written position papers defending coding positions when they are challenge
• Own regulatory change control across ICD-10-CM Official Guidelines, AHA Coding Clinic, and applicable payer and regulatory updates, and drive training and formal attestation for every coder and CDI reviewer on the standard in effect
• Build the coder quality rubric and inter-rater reliability standard used to measure our internal coding team
• Build the SQL reporting that sizes opportunity and measures policy impact, coder accuracy, and inter-rater reliability; partner with Compliance, CDI, Data Science, Actuarial/Finance, and Provider Network
• Keep management apprised of project activities through regular written and oral status reports, and proactively identify compliance and revenue risks that may hinder program success

Qualifications

• Required Certification/Licensure: Must possess and maintain AAPC Certified Risk Adjustment Coder (CRC) certification. CPC, CCS, RHIA, CDIP, or CCDS is a plus but not required
• 7+ years of experience in risk adjustment, including direct ownership of coding policy, clinical documentation integrity standards, or audit defense, not solely production coding
• Demonstrated experience authoring standards that others were required to follow, such as a coding policy manual, coding rules, documentation guidelines, quality rubrics, or audit protocols
• Working command of risk adjustment model mechanics, including the ability to reason about an unfamiliar model from its published specification
• Expert ICD-10-CM knowledge, fluent in the Official Guidelines and AHA Coding Clinic, with the judgment to recognize when a payment model’s rules are narrower than the code set’s
• Advanced SQL and Excel; comfort working with claims, encounter, supplemental, and pharmacy data
• Excellent written and verbal communication crafting documents that survive Compliance and Legal review while remaining usable by a coder
• Proficiency with healthcare coding software and Electronic Health Records (EHR) systems
• Ability to travel occasionally to our Orange, CA headquarters and, as needed, to other Astrana locations where our coding teams are based (up to 20% of work time)

• You have owned/authored coding policy 
• You have both payer-side and provider/MSO-side risk adjustment experience
• You have exposure to encounter data pipelines or managed care plan reporting
• You understand how program design creates or avoids False Claims Act exposure in risk adjustment
• You are comfortable declining a revenue-positive idea that the documentation or the model does not support, and can explain the reasoning
• You default to citation where every standard traces to a regulation, official guideline, model specification, or contract term
• You write for the reader who must apply the rule, and you would rather define a standard than inherit one
• You are organized, can prioritize competing high-priority work, and can work in a home office for continuous periods of time for business continuity

Environmental Job Requirements and Working Conditions

• This position is remotely based in the U.S. The home office is located at 1668 S. Garfield Ave. 2nd Floor, Alhambra, CA 91801.
• This role is required to attend occasional in-person meetings with internal departments and external providers/hospitals, training, or audit purposes. 
• The national target pay range for this role is between $90,000 - $120,000. Actual compensation will be determined based on geographic location (current or future), experience, and other job-related factors.

About
Astrana Health (NASDAQ: ASTH) is a physician-centric, technology-powered healthcare management company. We are building and operating a novel, integrated, value-based healthcare delivery platform to empower our physicians to provide the highest quality of end-to-end care for their patients in a cost-effective manner. Our mission is to combine our clinical experience, best-in-class delivery network, and technological expertise to improve patient outcomes, increase access to healthcare, and make the US healthcare system more efficient. Our platform currently empowers over 20,000 physicians to provide care for over 1.7 million patients nationwide. Our rapid growth and unique position at the intersection of all major healthcare stakeholders (payer, provider, and patient) gives us an unparalleled opportunity to combine clinical and technological expertise to improve patient outcomes, increase access to quality healthcare, and reduce the waste in the US healthcare system.