Risk Adjustment Compliance Specialist, Principal

Your Role

The Risk Adjustment Compliance Specialist, Principal is responsible for ensuring organizational compliance with laws related to Risk Adjustment across our Marketplace (ACA), Medicaid and Medicare Advantage lines of business. This role involves auditing, monitoring, and evaluating risk adjustment processes, identifying areas of non-compliance, and recommending corrective actions. The Principal collaborates with internal teams and external partners to maintain the integrity of risk adjustment data and supports the development and implementation of compliance programs.

Your Work

In this role, you will: 

• Conduct regular audits and reviews of risk adjustment data submissions to ensure compliance with regulatory requirements (e.g., CMS, OIG, HHS).
• Monitor changes in risk adjustment guidelines, policies, and regulations, and communicate updates to relevant stakeholders.
• Analyze risk adjustment processes and workflows to identify gaps, inefficiencies, or areas of non-compliance.
• Prepare reports and presentations summarizing audit findings, compliance risks, and recommendations for improvement.
• Collaborate with coding, clinical, and data management teams to ensure accurate and complete documentation for risk adjustment purposes.
• Assist in the development and implementation of training programs related to risk adjustment compliance for staff and providers.
• Support regulatory reporting and respond to compliance inquiries from internal and external auditors.
• Maintain documentation of compliance activities and findings in accordance with organizational policies.
• Participate in Risk Adjustment projects and initiatives, providing compliance expertise and guidance.
• Strategic thought partner to ensure Risk Adjustment programs are in line with Blue Shield of California strategic goals. 
• Build strategic internal and external relationships that support the goals of the teams. 
• Participate in the development and execution of corrective action plans to address identified compliance issues.
• Participates in the identification and assessment of potential compliance risks within risk adjustment processes and contributes to mitigation strategies. 

Your Knowledge and Experience

• Requires a college degree or equivalent experience. A degree in health care administration, business, public health, or related field is highly preferred
• Requires a certified Risk Adjustment Coder (CRC), Certified Professional Coder (CPC), Certified Coding Specialist (CCS), or equivalent credential
• Requires 10 years of relevant experience in Risk Adjustment, Healthcare Compliance, Medical Coding, or related area
• Requires strong knowledge of ICD-10-CM coding, HCC Risk Adjustment models (CMS-HCC and HHS-HCC), regulatory requirements, RADV audit documentation standards, and compliance standards
• Requires experience with data analysis, auditing, and reporting in a healthcare environment
• Requires excellent written and verbal communication skills, with the ability to convey complex information clearly
• Requires one to be detail-oriented, analytical, and able to manage multiple priorities in a fast-paced setting
• Requires proficiency in Microsoft Office Suite and relevant healthcare software applications
• Experience with ACA Marketplace (HHS-HCC) and/or Medi-Cal/Medicaid Managed Care Risk Adjustment programs is highly preferred

• Certification in Healthcare Compliance (CHC) is preferred

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About Blue Shield of California

As of January 2025, Blue Shield of California became a subsidiary of Ascendiun. Ascendiun is a nonprofit corporate entity that is the parent to a family of organizations including Blue Shield of California and its subsidiary, Blue Shield of California Promise Health Plan; Altais, a clinical services company; and Stellarus, a company designed to scale healthcare solutions. Together, these organizations are referred to as the Ascendiun Family of Companies. 

At Blue Shield of California, our mission is to create a healthcare system worthy of our family and friends and sustainably affordable. We are transforming health care in a way that genuinely serves our nonprofit mission by lowering costs, improving quality, and enhancing the member and physician experience. 

To achieve our mission, we foster an environment where all employees can thrive and contribute fully to address the needs of the various communities we serve. We are committed to creating and maintaining a supportive workplace that upholds our values and advances our goals.

Blue Shield is a U.S. News Best Company to work for, a Deloitte U.S. Best Managed Company and a Top 100 Inspiring Workplace. We were recognized by Fair360 as a Top Regional Company, and one of the 50 most community-minded companies in the United States by Points of Light. Here at Blue Shield, we strive to make a positive change across our industry and communities – join us!  

Our Values: 

• Honest. We hold ourselves to the highest ethical and integrity standards. We build trust by doing what we say we're going to do and by acknowledging and correcting where we fall short. 
• Human. We strive to listen and communicate effectively, showing empathy by understanding others' perspectives.
• Courageous. We stand up for what we believe in and are committed to the hard work necessary to achieve our ambitious goals. 

Physical Requirements:

Office Environment - roles involving part to full time schedule in Office Environment. Based in our physical offices and work from home office/deskwork - Activity level: Sedentary, frequency most of work day.

Please click here for further physical requirement detail. 

Equal Employment Opportunity:

External hires must pass a background check/drug screen. Qualified applicants with arrest records and/or conviction records will be considered for employment in a manner consistent with Federal, State and local laws, including but not limited to the San Francisco Fair Chance Ordinance. All qualified applicants will receive consideration for employment without regards to race, color, religion, sex, national origin, sexual orientation, gender identity, protected veteran status or disability status and any other classification protected by Federal, State and local laws.