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Risk Adjustment & Coding Lead (US)


  • CA, Cerritos
  • AZ, Tucson
  • CA, San Jose
  • VA, Richmond
  • Arizona, Arizona
  • California, California
  • CA, Cerritos



Work Location : Remote - Must be in Northern California

Responsible for conducting retrospective medical reviews to assess medical record documentation and monitoring submitted codes on claim/encounters for Medicare Risk Adjustment. 

Primary duties include, but are not limited to: 

•    Conducts prospective, concurrent, and retrospective medical record and claims review to assess medical record documentation practices and accuracy/sufficiency of policies and procedures. 
•    Verifies accuracy/appropriateness of submitted diagnosis codes based on medical record documentation looking at 1) appropriate detail in the medical record is not captured in what is reported, and 2) when reported information is not supported by details in the medical record.
•    Identifies and educates on compliant documentation and coding best practices to address unsupported additions/deletions, inconsistencies/discrepancies. 
•    Updates and develops policies and procedures and training/educating material to reflect best practices. 
•    Conducts ongoing review, monitoring and communications with assigned clinicians to promote and ensure adherence to established protocols and best practices. 
•    Reviews documentation of well visits (annual well visits and other routine and preventative visits) including the use of appropriate modifiers for HEDIS scoring accuracy. 
•    Conducts on-going review of encounter notes to monitor for performance improvement and identify new opportunities for education and training.
•    Requires BA/BS in health care or business and minimum of 2 years experience in healthcare industry and expertise in Risk Adjustment; or any combination of education and experience, which would provide an equivalent background. AAPC (American Academy of Professional Coders) or AHIMA (American Health Information Management Association) coding certification or equivalent certification required. 
•    Travel may be required. 

Preferred Qualifications:

•    2 years experience coding all types of medical records (including Medicare Risk Adjustment) in a physician practice setting or large group practice
•    Certified Clinical Documentation Specialist (CCDS, CCDS-O), Certified Documentation Expert Outpatient (CDEO) 
•    Current Certified Professional Coder certification (CPC, CPC-H, CRC, CCS, or CCS-P)
•    Additional experience in procedural clinical coding 
•    ISNP experience 
•    Clinical experience or background (e.g., RN, LPN, foreign medical graduates).

Please be advised that Elevance Health only accepts resumes from agencies that have a signed agreement with Elevance Health. Accordingly, Elevance Health is not obligated to pay referral fees to any agency that is not a party to an agreement with Elevance Health. Thus, any unsolicited resumes, including those submitted to hiring managers, are deemed to be the property of Elevance Health.

Be part of an Extraordinary Team

Elevance Health is a health company dedicated to improving lives and communities – and making healthcare simpler. Previously known as Anthem, Inc., we have evolved into a company focused on whole health and updated our name to better reflect the direction the company is heading.

We are looking for leaders at all levels of the organization who are passionate about making an impact on our members and the communities we serve. You will thrive in a complex and collaborative environment where you take action and ownership to solve problems and lead change. Do you want to be part of a larger purpose and an evolving, high-performance culture that empowers you to make an impact?

We offer a range of market-competitive total rewards that include merit increases, paid holidays, Paid Time Off, and incentive bonus programs (unless covered by a collective bargaining agreement), medical, dental, vision, short and long term disability benefits, 401(k) +match, stock purchase plan, life insurance, wellness programs and financial education resources, to name a few.

The health of our associates and communities is a top priority for Elevance Health. We require all new candidates to become vaccinated against COVID-19. If you are not vaccinated, your offer will be rescinded unless you provide – and Elevance Health approves – a valid religious or medical explanation as to why you are not able to get vaccinated that Elevance Health is able to reasonably accommodate. Elevance Health will also follow all relevant federal, state and local laws.

Elevance Health has been named as a Fortune Great Place To Work in 2021, is ranked as one of the 2021 World’s Most Admired Companies among health insurers by Fortune magazine, and a Top 20 Fortune 500 Companies on Diversity and Inclusion. To learn more about our company and apply, please visit us at Elevance Health is an Equal Employment Opportunity employer and all qualified applicants will receive consideration for employment without regard to age, citizenship status, color, creed, disability, ethnicity, genetic information, gender (including gender identity and gender expression), marital status, national origin, race, religion, sex, sexual orientation, veteran status or any other status or condition protected by applicable federal, state, or local laws. Applicants who require accommodation to participate in the job application process may contact for assistance.

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