Specialist, Risk Adjustment
Job description
About the role
Oscar Health is a technology-driven health insurance company that aims to make healthcare more accessible and affordable for its members through innovative digital tools and personalized care experiences. The Specialist, Risk Adjustment role is a remote position within the company's operations team, focused on ensuring accurate risk scoring and coding compliance across member health data. This role supports the broader goal of maintaining regulatory alignment and financial accuracy in risk adjustment processes that directly impact the company's reimbursement and member coverage models. The Specialist works closely with clinical and analytics teams to review member records and assign appropriate risk codes that reflect the true health status of the covered population. The position requires a detail-oriented professional who can manage large volumes of medical documentation while maintaining a high standard of coding precision. This role is integral to Oscar Health's mission of delivering high-quality, data-informed health insurance products to its members nationwide. The Specialist, Risk Adjustment position offers the chance to contribute meaningfully to Oscar Health's mission while working independently from a home office setup.
Key facts
What you'll do
Review and analyze member medical records to ensure accurate risk adjustment coding across all assigned accounts.
Collaborate with clinical teams to identify and document appropriate diagnosis codes based on patient encounter documentation.
Monitor risk adjustment data for compliance with federal and state regulatory requirements and coding standards.
Prepare detailed reports on risk score trends, coding accuracy metrics, and quality improvement opportunities.
Support the annual risk adjustment submission process with timely and accurate data entry and validation.
Conduct internal audits of coded claims to identify discrepancies, errors, or areas for process improvement.
Communicate detailed findings and actionable recommendations to leadership and cross-functional partners within the organization.
Maintain up-to-date knowledge of risk adjustment methodologies and current industry standards through ongoing education.
Assist in training junior staff members on coding guidelines, documentation requirements, and compliance procedures.
Coordinate with external vendors and auditors during risk adjustment review cycles and quality assurance checks.
Requirements
Bachelor's degree in health administration, nursing, public health, or a related field from an accredited institution.
Minimum of two years of professional experience in risk adjustment, medical coding, or health insurance operations.
Strong understanding of ICD-10-CM coding conventions, guidelines, and the principles of accurate diagnostic code assignment.
Solid working knowledge of HIPAA regulations and patient privacy requirements as they apply to health data handling.
Proven ability to analyze complex medical records and extract relevant clinical information for coding purposes.
Excellent written and verbal communication skills for effective collaboration with clinical, analytical, and operational teams.
Attention to detail with a consistent track record of accurate data entry and thorough documentation practices.
Experience working with electronic health record systems or claims management platforms in a healthcare or insurance setting.
Nice to have
Certification in risk adjustment coding such as CRC or CCS is a strong plus for this role.
Prior relevant experience working with Medicare Advantage or managed care organizations in a coding or compliance capacity.
Practical knowledge of Hierarchical Condition Category (HCC) models and risk scoring methodologies used in health insurance.
Prior hands-on experience with data visualization tools and interactive reporting dashboards for performance tracking.
Understanding of value-based care models and population health management concepts as they relate to risk adjustment.
Skills & tools
Proficiency with Microsoft Excel and data analysis spreadsheets for managing and reviewing large coding datasets.
Experience with electronic health record (EHR) systems and medical coding software used in healthcare environments.
Familiarity with risk adjustment platforms and claims processing tools commonly used in the insurance industry.
Strong working knowledge of ICD-10-CM and CPT coding systems and their application to member health data.
Ability to navigate health insurance regulatory databases and compliance resources for coding reference and verification.
Comfortable using internal reporting and analytics platforms for tracking coding metrics and quality indicators.
Practical notes
a fully remote position with no required in-office attendance or commuting obligations of any kind.
The role reports directly to the Risk Adjustment team lead within Oscar Health's operations department structure.
Standard business hours apply, with some schedule flexibility for meeting deadlines during peak submission periods.
Oscar Health offers a comprehensive benefits package including health coverage, retirement options, and professional development support.