Senior Risk Adjustment Coding Compliance Analyst (Clinical)

You could be the one who changes everything for our 28 million members. Centene is transforming the health of our communities, one person at a time. As a diversified, national organization, you’ll have access to competitive benefits including a fresh perspective on workplace flexibility. Applicants for this job have the flexibility to work remote from home anywhere in the Continental United States.

Executes Line 2 oversight of Risk Adjustment activities, including monitoring, auditing, and supports Line 1 oversight. Reviews medical records to assess proper extraction of medical diagnoses and ensure accurate and complete diagnosis coding in alignment with HCCs and other risk adjustment models. Identifies and evaluates clinical documentation gaps, assesses risk levels, and communicates findings to business stakeholders to support the integrity and quality of risk adjustment data. Collaborates with coding teams to improve documentation practices and ensure compliance with regulatory and coding guidelines.

Ensure coding accuracy by reviewing inpatient and outpatient medical records using clinical expertise to interpret documentation in accordance with ICD-10, Coding Clinic, AHIMA, and company coding guidelines. Validate clinical documentation to support appropriate risk adjustment coding, including Hierarchical Condition Categories (HCCs), with emphasis on clinical relevance and site of coding clinical appropriateness. Apply ICD-10, AHIMA standards, Coding Clinic guidance, and company policies to ensure accurate and compliant coding practices, incorporating clinical judgment to assess documentation sufficiency. Implement CMS risk adjustment guideline oversight and evaluate clinical documentation to ensure alignment with regulatory standards and coding compliance. Review and appropriately challenge coding decisions based on clinical interpretation of documentation, current industry guidelines, audit findings, and regulatory requirements. Conduct Line 1 gap analyses and provide clinical best practice recommendations; design and execute Line 2 oversight to evaluate the effectiveness and compliance of risk adjustment quality programs. Provide expert guidance on CMS coding requirements, clinical documentation improvement (CDI), and industry best practices to coding teams and providers. Assess risk levels in coding data using clinical insight and recommend mitigation strategies to address potential compliance or reimbursement risks. Support remediation efforts for identified non-compliance issues by applying clinical knowledge to root cause analysis and corrective action planning. Evaluate policies and procedures to ensure completeness, clinical accuracy, and adherence to current regulatory requirements and best practices. Perform clinical chart reviews and advise on clinical best practices related to risk adjustment coding, HCC capture, and documentation improvement. Performs other duties as assigned. Complies with all policies and standards.