Risk Adjustment Consultant

Tufts University School of Dental Medicine

. Perform accurate and timely reviews and validations of Medicare, Medicaid, Commercial HCCs, and DxCGs through medical record reviews .

Posted 9/30/2026full-timeRemote • Massachusetts • United StatesJuniorMid-Level💰 $72,372 - $90,465 per yearWebsite

Core Competencies

Role fit

Core Competencies

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Demonstrates expertise in ICD-10-CM coding standards and risk adjustment methodologies, with a strong focus on auditing and provider education. Capable of analyzing coding practices and collaborating with healthcare teams to ensure compliance with CMS guidelines.

Highest-signal resume keywords

Certified Risk Adjustment Coder (CRC)ICD-10-CM Coding StandardsOutpatient Billing and Coding ExperienceCMS Guidelines KnowledgeProvider Education and Feedback

ATS Keywords

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Applicant Tracking System Keywords

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Hard Skills

ICD-10-CM CodingCPT CodingRisk Adjustment AnalysisMedical Record ReviewAudit ReportingCoding Standards EvaluationDocumentation VerificationRegulatory Issue ResolutionData Trend AnalysisPre-Visit Chart Review

Soft Skills

Excellent Organizational SkillsInterpersonal SkillsAbility to Work Under PressureEffective Team CollaborationStrong Communication Skills

Certifications & Qualifications

Certified Risk Adjustment Coder (CRC)

Industry Keywords

MedicareMedicaidCommercial HCCsDxCGsOutpatient SettingsCoding GuidelinesRisk AdjustmentProvider DocumentationAudit FindingsCPT Codes

About the role

Key responsibilities & impact

Perform accurate and timely reviews and validations of Medicare, Medicaid, Commercial HCCs, and DxCGs through medical record reviews
Review provider documentation and verify ICD-10-CM coding against coding standards and CMS and Commercial Risk Adjustment guidelines
Evaluate HCC/DxCG coding practices and provide analyses and recommendations to improve provider documentation
Review medical records to verify ICD-10-CM and CPT codes accurately reflect provider documentation
Summarize audit findings for internal and external parties and provide provider education
Audit medical records for LCO groups and network providers to ensure diagnosis and CPT coding accuracy
Evaluate records for authorized providers, face-to-face CPT codes, signatures, and other technical requirements
Track audit results, identify trends, and recommend corrective actions
Collaborate with leadership, staff, and vendors to identify and submit coding adjustments
Provide education and feedback to physicians and network providers on risk adjustment and coding guidelines
Interpret coding guidelines and CMS regulations for leadership
Research and resolve coding and risk adjustment regulatory issues
Work retrospective/concurrent audit reports to close diagnosis gaps
Perform pre-visit chart reviews and provider outreach
Present recommendations and coding issue findings to key internal staff and leadership

Requirements

What you’ll need

Certified Risk Adjustment Coder (CRC) or must obtain within first 12 months of employment
Two (2) years of outpatient billing, coding, and risk adjustment experience
Associate’s degree preferred
Two (2) years of outpatient billing, coding, risk adjustment, and primary care adult medicine experience preferred
Extensive knowledge of ICD-10-CM coding standards
Strong understanding of coding rules and CMS guidelines in outpatient settings
Excellent organizational and interpersonal skills
Ability to work on multiple tasks, under pressure, meet deadlines, and provide excellent follow-up
Excellent oral and written communication skills
Ability to work effectively as a team member

Benefits

Comp & perks

Comprehensive Total Rewards package supporting health, financial security, and career growth