The expected pay range is based on many factors such as geography, experience, education, and the market. The range is subject to change.
What You Will Be Doing:
Under general supervision, the Risk Adjustment and Stars Coding Specialist is responsible for conducting prospective, concurrent, and retrospective medical record reviews to ensure the accurate assignment of ICD-10-CM diagnosis codes for risk adjustment and quality reporting purposes. This role supports coding accuracy, regulatory compliance, and document improvement across the organization. The coding specialist will identify coding and documentation trends, conduct chart audits, and collaborate with internal teams—including Quality and Provider Services—to support risk adjustment submissions and Stars performance. The role may also contribute to provider and staff education, audit readiness, and quality improvement initiatives.
Our Vision:
Continuously improve the health of our community.
Our Mission:
We provide healthcare value and advance wellness through community partnerships.
Essential Functions:
- Perform medical record reviews to identify, assign, and validate appropriate ICD-10-CM codes in accordance with CMS-HCC requirements.
- Evaluate provider documentation for completeness, accuracy, and compliance with Medicare Advantage and Medicaid risk adjustment requirements.
- Identify opportunities to capture unreported chronic conditions and care gaps based on data analysis and clinical insight.
- Initiate compliant provider queries when documentation is insufficient to support coding.
- Collaborate with internal teams and external partners to resolve documentation deficiencies and coding issues.
- Support risk adjustment data validation (RADV) readiness efforts and ensure adherence to CMS coding, Healthcare Effectiveness Data and Information Set (HEDIS), and Stars specifications.
- Contribute to the identification of documentation and coding trends to inform training and continuous quality improvement.
- Participate in ongoing process improvement initiatives, including inter-rater reliability (IRR) testing, coding audits, and peer review initiatives.
- Respond to suspected condition coding prompts (e.g., suspect HCCs) and contribute to associated data validation and submissions.
- Coordinate with vendors and IT teams to ensure timely and accurate transmission of risk adjustment and quality data to CMS and other regulatory bodies.
- Meet or exceed established benchmarks for coding productivity and accuracy.
Non-Essential Functions
- Support provider education efforts around documentation and coding best practices.
- Assist with internal staff training on regulatory and documentation changes.
Perform additional duties as assigned.
What You Bring:
Knowledge, Skills, Abilities and Competencies
Required
- Understanding of ICD-10-CM coding and the ability to analyze clinical documentation and apply coding guidelines accurately.
- Strong knowledge of medical terminology, anatomy, physiology, and pharmacology.
- High attention to detail with strong critical thinking and analytical skills.
- Excellent verbal and written communication skills, including the ability to explain complex coding issues to providers.
- Strong interpersonal skills with the ability to collaborate across departments and with external partners.
- Proficient in navigating electronic health record (EHR) systems and coding tools.
- Ability to manage confidential information with discretion.
- Skilled in prioritizing multiple tasks in a regulated, deadline-driven environment.
- Proficient in Microsoft Office applications, including Excel, Word, Outlook, and PowerPoint.
Preferred
- Familiarity with Stars/quality data specifications (e.g., HEDIS, CAHPS).
- Deep understanding of CMS-HCC models and risk adjustment methodologies.
- Familiarity with CMS RADV and OIG audits
- Experience with interrater reliability or coding QA/QC frameworks.
- Presentation and training skills for internal and external audiences.
- Experience contributing to policy and workflow development.
What You Have:
Education and Experience
Required
- Associate degree in healthcare administration, nursing, health information management, or other related field; or
- Four years of relevant medical coding experience in Medicare and Medicaid programs in lieu of degree.
Preferred
- Bachelor's degree in health information management, public health, or clinical discipline.
Licenses, Certifications
Required
- Certified Professional Coder (CPC); or
- Certified Outpatient Coder (COC) AND Certified Inpatient Coder (CIC); or
- Certified Coding Specialist-Physician-based (CCS-P); or
- Certified Coding Specialist (CCS)
Preferred
- Certified Risk Adjustment Coder (CRC)
- Registered Health Information Technician (RHIT)
What You Will Get:
HPSJ Perks:
- Competitive salary
- Robust and affordable health/dental/vision with choices in providers
- Generous paid time off (accrue up to 3 weeks of PTO, 4 paid floating holidays including employee’s birthday, and 9 paid holidays)
- CalPERS retirement pension program, automatic employer-paid retirements contributions, in addition to voluntary defined contribution plan
- Two flexible spending accounts (FSAs)
- Employer-Paid Term Life and AD&D Insurance
- Employer-Paid Disability Insurance
- Employer-Paid Life Assistance Program
- Health Advocacy
- Supplemental medical, legal, identity theft protection
- Access to exclusive discount mall
- Education and training reimbursement in addition to employer-paid elective learning courses.
- A chance to work for an organization that is mission-driven – our members and community are at the core of everything we do.
- A shorter commute – if you’re commuting from the Central Valley to the Bay Area.
- Visibility and variety – you have a chance to work with people at all levels of the organization, and work on diverse projects.
We are an equal opportunity employer and diversity is one of our core values. We believe that differences including race, ethnicity, gender, sexual orientation, and other characteristics, will help us create a strong organization that is sensitive to the needs of those we serve. Employment decisions are made on the basis of qualifications and merit.
HPSJ provides equal employment opportunities to employees and applicants for employment and prohibits discrimination based on color, race, gender (including gender identity and gender expression), religion (including religious dress and grooming practices), marital status, registered domestic partner status, age, national origin (including language use) or ancestry, physical or mental disability, medical condition (including cancer and genetic characteristics), sex (including pregnancy, childbirth, breastfeeding or related medical condition), genetic information, sexual orientation, military or veteran status, political affiliation or any other characteristic made unlawful by applicable Federal, State or local laws. It also prohibits unlawful discrimination based on the perception that anyone has these characteristics or is associated with anyone who has or is perceived to have these characteristics.
Important Notice: This job description is not a contract between HPSJ and the employee performing the job. The duties listed in the job description may be changed at the discretion of HPSJ, and HPSJ may request the employee to perform duties that are not listed on the job description.
Equal employment opportunity, including veterans and individuals with disabilities.
