ACO Coding Manager
- Hiring from
- United States
- Work type
- Remote
- Posted
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The ACO Coding Manager supports accurate, compliant, and clinically substantiated diagnosis coding across Medicare Shared Savings Program (MSSP), ACO REACH, LEAD, and like participant providers. This role combines expertise in risk adjustment coding, clinical documentation integrity, medical record auditing, provider education, and data analysis to ensure accurate representation of beneficiary disease burden and clinical complexity.
The Coding Manager conducts prospective and retrospective medical record reviews, analyzes coding and claims data, identifies documentation and coding opportunities, and delivers actionable education to physicians, advanced practice providers, and clinical teams. Through collaboration with Clinical Operations, Quality, Analytics, and Provider Engagement teams, this position helps strengthen risk adjustment performance, support population health initiatives, and enhance value-based care outcomes.
The ideal candidate is a certified professional coder with experience in Medicare risk adjustment and a strong understanding of HCC methodologies, RAF analytics, ICD-10-CM coding guidelines, CMS documentation requirements, and coding compliance principles. The successful candidate will possess strong analytical, communication, and presentation skills, with the ability to translate complex coding and documentation concepts into practical guidance for providers and operational leaders.
This version subtly elevates the role from a "coder" to a clinical performance and provider education resource, which seems more consistent with the direction you're taking with Coding and Quality reporting into a Clinical Operations/Integration structure.
Key Responsibilities:
Risk Adjustment Analytics
- Analyze claims, encounter, clinical, and coding data to identify HCC, RAF, documentation, and risk adjustment opportunities.
- Monitor coding performance, suspect conditions, recapture rates, disease burden trends, and provider variation.
- Conduct provider-, practice-, and ACO-level analyses to identify opportunities for improvement.
- Translate coding and risk adjustment findings into actionable recommendations for providers and operational leaders.
- Partner with analytics teams to support coding dashboards, reporting, and performance measurement.
- Maintain knowledge of CMS-HCC methodologies and annual model updates.
Coding & Clinical Documentation Review
- Conduct prospective and retrospective medical record reviews to validate diagnosis coding accuracy and documentation support.
- Ensure compliance with ICD-10-CM coding guidelines, CMS requirements, and risk adjustment standards.
- Identify coding, documentation, and clinical validation opportunities and communicate findings to providers and operational teams.
- Perform targeted coding audits and support corrective action planning as needed.
- Maintain audit documentation and assist with internal, CMS, and RADV-related audit activities.
Provider Education & Engagement
- Develop and deliver provider education on risk adjustment, HCC coding, documentation improvement, coding compliance, and CMS requirements.
- Provide individual and group coaching based on coding audits, performance trends, and documentation opportunities.
- Create educational materials, webinars, job aids, and e-learning resources.
- Present coding and risk adjustment performance results to providers, clinical teams, and leadership.
- Evaluate the effectiveness of educational initiatives through audit and performance outcomes.
Compliance & Collaboration
- Promote compliant coding and documentation practices consistent with CMS and ACO program requirements.
- Monitor regulatory and policy changes related to coding, documentation, risk adjustment, and audit readiness.
- Collaborate with Clinical Operations, Quality, Analytics, Compliance, and participating provider organizations.
- Support the development and maintenance of coding policies, audit protocols, and educational standards.
- Identify and escalate coding compliance risks as appropriate.
Qualifications:
- Current coding certification (CPC, CCS, CCS-P, CRC, or equivalent).
- 3-5 years of coding, risk adjustment, auditing, or related healthcare experience.
- Experience with Medicare HCC coding, RAF methodologies, and clinical documentation review.
- Strong knowledge of ICD-10-CM coding guidelines and CMS documentation requirements.
- Experience conducting medical record audits and communicating findings to providers.
- Understanding of clinical validation, RADV principles, and audit methodologies.
- Experience analyzing claims, EHR, encounter, or risk adjustment data.
- Strong analytical, communication, presentation, and provider education skills.
- Proficiency with Microsoft Excel and healthcare reporting or analytics tools.
Preferred Qualifications
- CRC certification.
- Experience supporting MSSP, ACO REACH, LEAD, Medicare Advantage, or other value-based care programs.
- Experience conducting provider-level HCC, RAF, and coding performance analysis.
- Experience with CMS audits, RADV preparation, or compliance reviews.
- Experience developing provider education and training programs.
- Familiarity with Medicare claims, CCLF data, and population health analytics platforms.
- Experience serving complex, high-risk, frail, institutional, or dual-eligible Medicare populations.