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Department:  Business Services
Status:  Full Time
Shift:  1st

Hoag is seeking a Risk Adjustment Manager for the Physician Coding, Education and Auditing Process. 


Essential Functions:

  • Lead the HCC coding team and reviewing procedures, HCPCS/ HCC and diagnosis coding for accuracy
  • Provide education practice leadership to assist in the identification of clinical best practices to ensure diagnoses are captured in accordance with CMS Risk Adjustment coding guidelines.
  • Partners payers and vendors to provide education and reporting to the HCC team.
  • Manage provider coding accuracy audits in coordination with Clinical leadership to support provider performance tracking and incentive measures
  • Coordinate with enterprise Compliance to establish RADV mock audit process and RADV Audit responses  
  • On-site review and analysis of provider HCC documentation with an eye toward compliance with CMS rules and regulations to capture risk adjusting (HCC) diagnoses
  • Co-develop with HMG Clinical Leadership provider education curriculum to ensure ongoing best practices in documenting diagnoses to the highest level of specificity
  • Develop customized education plans for assigned providers to address opportunities for clinical document improvements identified during the review
  • Assist with the development, implementation, and oversight of team projects. 
  • Creation of job aids detailing coding rules and process for global teams
  • Create and administer assessments to evaluate the comprehension of training efforts
  • Ensure coder production is being met to satisfy client needs and contractual requirements; providing employees with QA and feedback
  • Other duties as assigned



  • Bachelor’s Degree in finance, economics, health administration, business administration or related field required. Masters’ Degree preferred.
  • Credentials to include one or a combination of the following: RHIA, RHIT CCS and/or CPC.
  • Minimum five years of risk adjustment coding experience; minimum of three years’ experience supervising risk adjustment staff and programs.
  • Previous auditing of clinical data in physician offices or medical facilities required.
  • Knowledge of health care insurance claims practice and compliance.
  • Extensive knowledge of Medicare and CMS Risk Adjustment payment rules, regulations and guidelines as it relates to managed care organizations required..
  • Knowledge of CPT, ICD-9, ICD-10, DRG, APC/ASC, HEDIS, AAPCC, Medicare services and reimbursement methodologies, revenue codes and RBRVS.
  • Knowledge of risk adjustment categories and hierarchy.
  • Experience with EPIC EMR
  • Preferred Certified Risk Adjustment Coder (CRC) or Certified Professional Coder (CPC).
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