Senior Risk Adjustment Operations Specialist

The Senior Risk Adjustment Operations Specialist serves as a key liaison among risk adjustment coders, primary care providers (PCPs), provider office staff, and internal stakeholders. The role translates coding and documentation findings into practical, provider-facing education and operational follow-up that improves HCC capture, recapture, documentation specificity, and coding accuracy. This position supports risk adjustment performance by helping provider offices strengthen clinical documentation practices, close documentation gaps, and integrate sustainable workflows at the point of care.

• Provider and Coder Liaison: Serve as the primary operational link between coding teams and assigned PCP practices. Facilitate timely, clear, and actionable communication regarding coding findings, documentation opportunities, and recurring provider-office barriers.
• Provider Education and Feedback: Deliver individual and group education to PCPs, advanced practice clinicians, and office staff on compliant HCC documentation, MEAT principles, condition specificity, annual recapture, and documentation requirements that support accurate coding.
• Coding Feedback Facilitation: Review coder feedback and translate technical findings into provider-friendly guidance. Coordinate case-level follow-up, clarify documentation questions, and track resolution of identified issues without directing or influencing unsupported diagnosis coding.
• Documentation Improvement: Identify patterns in incomplete, nonspecific, conflicting, or insufficient documentation and recommend practical improvements to workflows, templates, visit preparation, and follow-up processes.
• HCC Performance Improvement: Use risk adjustment reports, suspect conditions, recapture lists, and coding trends to prioritize provider outreach and education while promoting accurate and complete documentation of conditions evaluated, assessed, treated, or monitored during the encounter.
• Provider Office Workflow Support: Assess front- and back-office processes that affect pre-visit planning, annual wellness visits, chart preparation, encounter submission, medical record retrieval, and response to coding queries. Partner with practices on corrective action plans and monitor progress.
• Data and Trend Analysis: Analyze provider-level and coder-level findings to identify training needs, recurring documentation deficiencies, coding variances, and operational risks. Summarize themes and recommend targeted interventions.
• Quality Assurance and Compliance: Support coding quality assurance activities and ensure education aligns with current ICD-10-CM Official Guidelines for Coding and Reporting, CMS risk adjustment requirements, organizational policies, and ethical coding standards.
• Audit Readiness: Maintain complete records of provider education, outreach, feedback, attendance, issue resolution, and corrective actions. Assist with internal audits, compliance reviews, and CMS RADV or other regulatory audit readiness activities.
• Cross-Functional Collaboration: Collaborate with Risk Adjustment, Quality/Stars, Provider Relations, Clinical, Compliance, IT/Data Analytics, and vendor partners to resolve issues and improve provider performance.
• Program and Project Support: Participate in risk adjustment initiatives, provider campaigns, system implementations, process redesign, and special projects. Assist with testing reports and workflows and provide operational feedback.
• Continuous Improvement: Develop and maintain standard work, job aids, training materials, FAQs, and provider-facing tools. Recommend process improvements that improve accuracy, timeliness, provider experience, and scalability.

• Provider education and outreach are completed accurately, professionally, and within established turnaround times.
• Coding and documentation issues are tracked through resolution, with clear ownership and follow-up.
• Provider-specific education addresses documented trends and results in measurable improvement in documentation quality, HCC recapture, or coding accuracy.
• All education and communications reinforce compliant documentation and coding practices and do not encourage unsupported diagnosis capture.
• Program activity, outcomes, barriers, and escalation needs are reported using established dashboards or tracking tools.

• Bachelor’s degree in healthcare administration, health information management, nursing, business, or a related field; equivalent relevant experience may be considered.
• Five or more years of progressive experience in Medicare Advantage risk adjustment, HCC coding operations, clinical documentation improvement, provider education, or a related healthcare function.
• Current professional coding credential such as CPC, CCS, CCS-P, CRC, RHIA, or RHIT is strongly preferred; CRC or comparable risk adjustment credential is preferred.
• Demonstrated knowledge of ICD-10-CM coding, CMS-HCC risk adjustment, documentation requirements, and compliant provider education practices.
• Experience working directly with physicians, advanced practice clinicians, coding professionals, and provider office staff.
• Proficiency with Microsoft Office applications and experience using risk adjustment, coding, electronic health record, provider portal, or reporting platforms.

• Health plan, IPA, medical group, MSO, or provider-practice experience supporting Medicare Advantage populations.
• Experience conducting provider-facing education, field visits, virtual training, and performance improvement follow-up.
• Knowledge of CMS RADV, coding audit processes, encounter data, chart review operations, and HCC recapture workflows.
• Experience developing training materials, job aids, standard operating procedures, and action plans.
• Bilingual capability aligned with the needs of the provider network is a plus.

• Ability to explain complex coding and documentation concepts in clear, practical language for clinical and nonclinical audiences.
• Strong facilitation, presentation, relationship-management, and conflict-resolution skills.
• Excellent written and verbal communication with sound judgment and a customer-service mindset.
• Ability to interpret provider-level data, identify root causes, and convert findings into measurable action plans.
• High attention to detail, organization, follow-through, and documentation integrity.
• Ability to manage multiple provider assignments, deadlines, and priorities in a fast-paced environment.
• Ability to maintain confidentiality and comply with HIPAA, company policy, ethical coding standards, and applicable regulatory requirements.
• Ability to work independently while collaborating effectively across teams and escalating material risks appropriately.

This position does not have direct supervisory responsibility but may provide functional guidance, workflow support, peer coaching, and subject matter expertise to coding and operational staff.

$81,500/year - $100,000/year

This role routinely uses standard office equipment and requires extended periods of computer and telephone use. The employee must be able to communicate effectively in person and through virtual platforms. Occasional travel to provider offices, company locations, meetings, or training events may be required. Reasonable accommodations may be made to enable qualified individuals with disabilities to perform the essential functions of the position.

Clever Care Health Plan is proud to be an Equal Employment Opportunity and Affirmative Action workplace. Individuals seeking employment will receive consideration for employment without regard to race, color, national origin, religion, age, sex (including pregnancy, childbirth or related medical conditions), sexual orientation, gender perception or identity, age, marital status, disability, protected veteran status or any other status protected by law. A background check is required. 

Salary ranges posted on the job posting are based on California wages. Salary may be higher or lower depending on the candidate’s state residency. 

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