The Risk Adjustment Compliance Specialist, Principal is responsible for ensuring organizational compliance with laws related to Risk Adjustment across our Marketplace (ACA), Medicaid and Medicare Advantage lines of business. This role involves auditing, monitoring, and evaluating risk adjustment processes, identifying areas of non-compliance, and recommending corrective actions.
The Principal collaborates with internal teams and external partners to maintain the integrity of risk adjustment data and supports the development and implementation of compliance programs.
- Requires a college degree or equivalent experience. A degree in health care administration, business, public health, or related field is highly preferred
- Requires a certified Risk Adjustment Coder (CRC), Certified Professional Coder (CPC), Certified Coding Specialist (CCS), or equivalent credential
- Requires 10 years of relevant experience in Risk Adjustment, Healthcare Compliance, Medical Coding, or related area
- Requires strong knowledge of ICD-10-CM coding, HCC Risk Adjustment models (CMS-HCC and HHS-HCC), regulatory requirements, RADV audit documentation standards, and compliance standards
- Requires experience with data analysis, auditing, and reporting in a healthcare environment
- Requires excellent written and verbal communication skills, with the ability to convey complex information clearly
- Requires one to be detail-oriented, analytical, and able to manage multiple priorities in a fast-paced setting
- Requires proficiency in Microsoft Office Suite and relevant healthcare software applications
- Experience with ACA Marketplace (HHS-HCC) and/or Medi-Cal/Medicaid Managed Care Risk Adjustment programs is highly preferred
- Certification in Healthcare Compliance (CHC) is preferred
- Conduct regular audits and reviews of risk adjustment data submissions to ensure compliance with regulatory requirements (e.g., CMS, OIG, HHS).
- Monitor changes in risk adjustment guidelines, policies, and regulations, and communicate updates to relevant stakeholders.
- Analyze risk adjustment processes and workflows to identify gaps, inefficiencies, or areas of non-compliance.
- Prepare reports and presentations summarizing audit findings, compliance risks, and recommendations for improvement.
- Collaborate with coding, clinical, and data management teams to ensure accurate and complete documentation for risk adjustment purposes.
- Assist in the development and implementation of training programs related to risk adjustment compliance for staff and providers.
- Support regulatory reporting and respond to compliance inquiries from internal and external auditors.
- Maintain documentation of compliance activities and findings in accordance with organizational policies.
- Participate in Risk Adjustment projects and initiatives, providing compliance expertise and guidance.
- Strategic thought partner to ensure Risk Adjustment programs are in line with Blue Shield of California strategic goals.
- Build strategic internal and external relationships that support the goals of the teams.
- Participate in the development and execution of corrective action plans to address identified compliance issues.
- Participates in the identification and assessment of potential compliance risks within risk adjustment processes and contributes to mitigation strategies.