Coding Analyst - Risk Adjustment

The pay range above represents the minimum and maximum rate for this position in California. Factors that may be used to determine where newly hired employees will be placed in the pay range include the employee specific skills and qualifications, relevant years of experience and comparison to other employees already in this role. Most often, a newly hired employee will be placed below the midpoint of the range. Salary range will vary for remote positions outside of California and future increases will be based on the pay band for the city and state you reside in.

Work Culture:

GCHP strives to create an inclusive, highly collaborative work culture where our people are empowered to grow and thrive.  This philosophy enables us to create the health plan of the future and do our best work – Together.

GCHP promotes a flexible work environment. Employees may work from a home location or in the GCHP office for all or part of their regular workweek (see disclaimer).

GCHP’s focuses on 5 Core Values in the workplace:

•    Integrity

•    Accountability

•    Collaboration

•    Trust 

•    Respect

Disclaimers:

•    Flexible work schedule is based on job duties, department, organization, or business need.

•    Gold Coast Health Plan will not sponsor applicants for work visas.

POSITION SUMMARY

The Coding Analyst – Risk Adjustment plays a critical role in aligning financial performance with coding accuracy and risk adjustment processes. This position combines expertise in financial analysis, medical coding, and risk adjustment to optimize revenue and ensure compliance with CMS (Centers for Medicare & Medicaid Services), HHS (Health and Human Services), and other regulatory requirements. The role supports financial modeling, data integrity, and coding audits while providing actionable insights for improving documentation and maximizing risk-adjusted revenue.

Amount of Travel Required: 5-10%

Work Environment:

•    Flexible work arrangement (remote, hybrid, or onsite depending on organizational policies)

•    May require occasional travel for training, provider engagement, or audits

Reasonable Accommodations Statement

To accomplish this job successfully, an individual must be able to perform, with or without reasonable accommodation, each essential function satisfactorily. Reasonable accommodations may be made to help enable qualified individuals with disabilities to perform the essential functions.

ESSENTIAL FUNCTIONS

Job Function & Responsibilities

•    Financial Analysis and Risk Adjustment Modeling

•    Analyze financial data related to risk adjustment revenue streams for Medicare Advantage and Medicaid populations

•    Perform revenue impact modeling based on coding accuracy, member health profiles, and risk scores (e.g., HCC, RxHCC), including development of accrual estimates for financial reporting purposes

•    Develop and monitor financial forecasts tied to risk adjustment performance

•    Coding Audit and Review

•    Collaborate with coding and clinical teams to ensure the accuracy of ICD-10-CM codes submitted for risk adjustment purposes

•    Audit medical records for compliance with CMS-HCC, HHS-HCC, and other risk adjustment models.

•    Identify and analyze coding gaps or errors that impact financial outcomes

•    Compliance and Regulatory Support

•    Ensure alignment with CMS, RADV (Risk Adjustment Data Validation), and other regulatory requirements for risk adjustment submissions

•    Support internal and external audits, including providing documentation and financial justifications.

•    Stay updated on changes in risk adjustment policies, coding guidelines, and financial implications.

•    Work with providers to understand the financial impact of coding and documentation practices on risk adjustment revenue

•    Provide financial feedback and insights to support documentation improvement initiatives.

•    Partner with internal teams (e.g., actuarial, clinical, and compliance) to align financial and operational goals

•    Generate detailed reports on risk scores, revenue impact, and coding trends for senior management and key stakeholders

•    Evaluate the financial implications of provider documentation and coding practices.

•    Collaborate with data analytics teams to design and enhance reporting tools that monitor risk adjustment performance

•    Other duties as assigned

MINIMUM QUALIFICATIONS

Education:

•    Bachelor’s degree in finance, Accounting, Health Information Management, or a related field (required).

•    Certified Professional Coder (CPC), Certified Risk Adjustment Coder (CRC), or equivalent certification (preferred).

•    Advanced degrees or certifications (e.g.,, CFA, MBA) are a plus.

Experience:

•    3–5 years of experience in financial analysis, medical coding, or risk adjustment within a health plan or managed care organization.

•    Strong knowledge of CMS-HCC, HHS-HCC, and RADV processes.

•    Experience in data-driven financial modeling, risk adjustment, and coding audits.

KNOWLEDGE, SKILLS & ABILITIES  

Preferred Qualifications:    

•    Proficiency in data analysis tools (e.g., Excel) and financial modeling

•    Strong understanding of ICD-10-CM coding guidelines and risk adjustment methodologies

•    Exceptional analytical and problem-solving skills with attention to detail

•    Excellent communication and presentation skills for financial and operational stakeholders

•    Ability to prioritize and manage multiple tasks in a fast-paced environment

•    Experience with risk adjustment data submission platforms

•    Familiarity with MediCal and Medicare Advantage financial models

•    Prior experience in a health plan or managed care setting

Competency Statements

•    Business Acumen - Ability to grasp and understand business concepts and issues.

•    Presentation Skills - Ability to effectively present information publicly.

•    Communication, Oral - Ability to communicate effectively with others using the spoken word.  

•    Communication, Written - Ability to communicate in writing clearly and concisely.  

•    Problem Solving - Ability to find a solution for or to deal proactively with work-related problems.