Lead HCC Risk Adjustment Medical Coder

Job Summary

We are seeking an experienced medical coding and risk adjustment leader to manage and strengthen our coding, quality, compliance, and clinical documentation improvement functions.

The role will oversee end-to-end medical coding operations across HCC risk adjustment, inpatient and outpatient coding, emergency department, evaluation and management, ambulatory surgery center, and other multispecialty coding programs.

The selected professional will be responsible for improving coding accuracy, documentation quality, revenue integrity, operational performance, and regulatory compliance. The role will also involve team leadership, client engagement, process transitions, quality governance, performance analytics, and implementation of technology-enabled coding solutions.

This position is suitable for a senior healthcare professional who can combine medical coding expertise with operational leadership, quality improvement, client management, and digital transformation.

Key Responsibilities

Medical Coding and Risk Adjustment

• Lead end-to-end medical coding operations for provider and payer programs.
• Oversee HCC risk adjustment coding for Medicare Advantage and other health plan programs.
• Ensure accurate capture of HCCs, chronic conditions, disease specificity, complications, comorbidities, and patient acuity.
• Review RAF-related coding outcomes and support reimbursement and revenue-integrity objectives.
• Provide coding oversight across inpatient, outpatient, emergency department, E/M, ASC, surgery, and multispecialty coding.
• Ensure correct application of ICD-10-CM, CPT, HCPCS, ICD-10-PCS, MS-DRG, and APR-DRG guidelines.
• Support CDI initiatives for physician and hospital coding programs.
• Identify documentation gaps, unsupported diagnoses, coding discrepancies, and improvement opportunities.

Quality and Compliance

• Establish and manage coding-quality, audit, and compliance frameworks.
• Conduct or oversee coding audits, HCC reviews and documentation-quality assessments.
• Develop sampling methodologies, calibration processes, quality scorecards, and audit-review mechanisms.
• Perform root-cause analysis and implement corrective and preventive actions for coding-quality issues.
• Monitor compliance with CMS, HIPAA, NCCI, payer policies, LCDs, NCDs, and client-specific guidelines.
• Support audit readiness, revenue-integrity reviews, and risk-mitigation initiatives.
• Identify documentation and coding gaps that may affect reimbursement or create audit exposure.

Operations and Delivery Management

• Manage coding operations, resource planning, workflow allocation, productivity, quality, and turnaround time.
• Establish and monitor operational KPIs, KRAs, SLAs, quality scores, and delivery metrics.
• Design and standardize workflows, SOPs, escalation matrices, and operating procedures.
• Lead new-client transitions, pilot programs, process implementations, and go-live activities.
• Analyze operational performance and implement continuous-improvement initiatives.
• Support capacity planning, staffing, productivity optimization, and cost management.
• Collaborate with billing, AR, compliance, clinical, and revenue-cycle teams to improve clean-claim rates and reduce denials.

Team Leadership and Development

• Lead managers, team leaders, quality analysts, SMEs, and medical coders.
• Mentor coding and quality teams on HCC and multispecialty coding requirements.
• Develop training programs, refresher sessions, and performance-improvement plans.
• Monitor team productivity, coding accuracy, audit results, and adherence to compliance standards.
• Build leadership capability within the coding and quality functions.
• Support recruitment, onboarding, certification development, and succession planning.

Client and Stakeholder Management

• Serve as a senior point of contact for US healthcare clients and internal stakeholders.
• Conduct operational reviews, governance meetings, and performance discussions.
• Present coding trends, quality outcomes, compliance risks, and improvement recommendations.
• Understand client requirements and translate them into scalable operational workflows.
• Manage escalations, client feedback, and service-improvement initiatives.
• Identify opportunities for account growth, service expansion, and value-added solutions.

Technology and Process Transformation

• Collaborate with product, analytics, and technology teams on coding automation initiatives.
• Provide medical-coding domain expertise for clinical-documentation mapping and coding-rule development.
• Participate in user-story definition, testing, validation, implementation, and post-go-live reviews.
• Use data analytics and dashboards to monitor coding accuracy, productivity, denial trends, and operational performance.

Required Qualifications

• CPC/CRC certification.
• Significant leadership experience in medical coding or healthcare operations.
• Strong hands-on and managerial knowledge of HCC risk adjustment and Medicare Advantage coding.
• Strong knowledge of ICD-10-CM, CPT, HCPCS, ICD-10-PCS, E/M, ED, inpatient, and outpatient coding.
• Experience with MS-DRG, APR-DRG, ASC, or multispecialty coding programs.
• Experience managing coding-quality audits, compliance reviews, and performance-improvement initiatives.
• Strong understanding of CMS, HIPAA, NCCI, payer policies, and coding-compliance requirements.
• Experience managing large coding, quality, or RCM teams.
• Experience in client engagement, process transitions, operational governance, and SLA management.
• Strong analytical, communication, leadership, documentation, and stakeholder-management skills.

Preferred Qualifications

• CRC, CPC, or additional risk-adjustment, coding, or CDI certification. .
• Experience in Clinical Documentation Improvement and revenue-integrity programs.
• Experience with denial prevention, hospital audits, and coding-gap analysis.
• Exposure to AI, NLP, computer-assisted coding, or healthcare-product implementation.
• Experience working with EHR, billing, and coding platforms.
• Educational background in biochemistry, life sciences, healthcare, or a related discipline.

Key Performance Indicators

• Coding accuracy and quality scores.
• HCC and risk-adjustment accuracy.
• SLA and turnaround-time achievement.
• Productivity and utilization.
• Audit variance and compliance performance.
• Denial-rate reduction.
• Client satisfaction and retention.
• Team performance and certification development.
• Successful project transitions and process implementations.
• Revenue integrity and operational improvement outcomes.