Risk Adjustment QA Consultant

As a Risk Adjustment Quality Assurance (QA) Consultant at BCBSMN, you'll play a critical role in ensuring the accuracy, completeness, and compliance of risk adjustment coding across both internal teams and external partners. Your work will help uphold the highest standards in documentation and coding practices-protecting against fraud, waste, and abuse. In this influential role, you'll design and implement QA strategies, educate stakeholders on the impact of their work, and use performance metrics to proactively identify and resolve issues-making a measurable difference in the quality and integrity of our healthcare data.

• Ensure accuracy and compliance of risk adjustment coding, including the appropriate coding of diagnoses and documentation of patient conditions.
• Primary support to any HHS and CMS RADV audits, including retrieval and coding of targeted medical records.
• Design and implement QA programs to improve coding accuracy, reduce errors, and prevent fraud.
• Collaborate with Provider Network, Clinical and Care Management teams to align risk adjustment initiatives with population health, care coordination, and quality improvement programs.
• Educate internal and external stakeholders, including coders and clinical staff, on proper coding practices and compliance requirements.
• Manage medical coding metrics, performance improvement opportunities, and evaluation of in-home assessments, chart reviews, and point-of-care programs.
• Conduct audits of coding practices, identifying areas for improvement, and developing and implementing corrective action plans.
• Assess outsourced coding vendors to ensure performance, compliance and provide feedback.
• Stay abreast of changes in coding guidelines, regulations, and risk adjustment methodologies.

• 5+ years of relevant professional experience. All relevant experience including work, education, transferable skills, and military experience will be considered.
• Experience in medical coding with a focus on Medicare Advantage and ACA risk adjustment.
• Certified Risk Adjustment Coder (CRC) certification
• In-depth knowledge of ACA & Medicare Advantage risk adjustment methodology, coding guidelines (ICD-10-CM), healthcare compliance, and billing practices.
• Proficiency in Excel and PowerPoint.
• Excellent writing skills.
• Excellent presentation skills.
• High school diploma (or equivalency) and legal authorization to work in the U.S.

• Bachelor's degree
• Experience in provider office medical coding, claims auditing, or specialty clinics.
• Certifications such as CPMA, RHIT, RHIA, CCA, CCS.
• Expertise in CMS-HCC, and HHS-HCC Risk Adjustment models.

Compensation and Benefits:

Pay Range: $88,600.00 - $117,400.00 - $146,200.00 Annual

Pay is based on several factors which vary based on position, including skills, ability, and knowledge the selected individual is bringing to the specific job.

We offer a comprehensive benefits package which may include:

• Medical, dental, and vision insurance
• Life insurance
• 401k
• Paid Time Off (PTO)
• Volunteer Paid Time Off (VPTO)
• And more

To discover more about what we have to offer, please review our benefits page.

Role Designation

Hybrid

Anchored in Connection

Our hybrid approach is designed to balance flexibility with meaningful in-person connection and collaboration.
We come together in the office two days a week-one designated anchor day with your team, and one day of your choosing.
These in-person moments foster relationships, creativity, and alignment.
The rest of the week you are empowered to work remote.