Role Description
Avail Health is a rapidly growing value-based care company delivering comprehensive, technology-enabled care programs to Medicare patients with complex medical, behavioral health, and social needs. Our care model spans a range of clinical programs including Comprehensive Diagnostic Assessments (CDAs), Health Risk Assessments (HRAs), and Integrated Care Programs (ICPs), all designed to address the whole-person needs of high-risk Medicare beneficiaries.
As Avail Health continues to scale its clinical programs, we are seeking an experienced Risk Adjustment & Coding Expert to serve as a trusted fractional advisor to our clinical and operational leadership team. This role sits at the intersection of clinical documentation, Medicare coding compliance, and program-level performance—supporting our mission to deliver high-quality, accurately documented care that reflects the true complexity of our patient population.
The Risk Adjustment & Coding Expert will:
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Advise clinical leaders on proper HCC (Hierarchical Condition Category) coding practices.
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Ensure documentation integrity across Avail's care programs.
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Drive ongoing workflow design, policy development, and process improvement to support accurate and compliant risk adjustment coding.
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Function as a subject-matter expert embedded within Avail's interdisciplinary team structure.
This is a startup-style healthcare environment where subject-matter experts are expected to be hands-on, pragmatic, and solutions-oriented. The ideal candidate brings deep Medicare Advantage risk adjustment expertise, strong knowledge of CMS coding guidelines, and a track record of building scalable coding education and quality programs within complex care or value-based care organizations.
Qualifications
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Must have Certified Risk Adjustment Coder (CRC); Certified Professional Coder (CPC) also highly desirable.
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Minimum 5 years of experience in Medicare risk adjustment coding, HCC coding, or clinical documentation improvement (CDI) required.
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Deep knowledge of ICD-10-CM coding guidelines, CMS HCC models (V24, V28), and Medicare Advantage risk adjustment methodology.
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Experience working in value-based care, Medicare Advantage, population health, or complex care management environments strongly preferred.
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Prior experience advising clinical providers (NPs, MDs, RN Care Managers) on coding and documentation practices.
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Experience designing or delivering coding education and training programs for clinical teams.
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Familiarity with CDAs, HRAs, Annual Wellness Visits (AWVs), and Transitional Care Management (TCM) coding preferred.
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Experience with RADV audits, coding compliance programs, and risk adjustment quality initiatives preferred.
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Proficiency with EMR platforms, coding tools, and documentation review workflows.
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Ability to work independently in a fractional/part-time capacity with strong self-direction and accountability.
Requirements
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Perform audits on existing coding staff.
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Serve as the primary coding and risk adjustment subject-matter expert for Avail Health clinical leaders and frontline clinicians across CDAs, HRAs, and ICPs.
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Advise Nurse Practitioners, Physicians, and RN Care Managers on accurate ICD-10-CM coding, HCC capture, and documentation requirements to support proper Medicare risk adjustment.
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Review clinical encounter documentation and provide real-time feedback on coding accuracy, specificity, and completeness.
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Identify coding gaps, missed HCC capture opportunities, and documentation deficiencies across care programs and patient populations.
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Provide guidance on condition-specific coding requirements for high-prevalence chronic conditions within Avail's patient population (e.g., diabetes, CHF, COPD, CKD, behavioral health diagnoses).
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Partner with clinical and operational leadership to design and implement coding workflows integrated into Avail's care program delivery model.
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Develop and maintain coding and documentation policies, guidelines, and standard operating procedures (SOPs) aligned with CMS requirements and Medicare Advantage risk adjustment best practices.
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Support the development of documentation templates, encounter coding checklists, and structured data capture tools within the EMR and care coordination platforms.
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Define escalation pathways and quality review workflows for coding discrepancies, queries, and corrections.
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Design and deliver ongoing coding education and training programs for Avail's clinical team, including onboarding content for new clinicians and refresher training for existing staff.
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Develop program-specific coding guides, quick-reference tools, and clinical documentation resources for CDAs, HRAs, and ICPs.
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Partner with the VP of Care Delivery and Medical Director to integrate coding best practices into clinical workflows, quality reviews, and care team huddles.
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Support providers in navigating complex coding scenarios including dual diagnoses, behavioral health coding, and social determinants of health (SDOH) documentation.
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Conduct coding audits and documentation reviews across a sample of clinical encounters to assess coding accuracy, completeness, and compliance with CMS and Medicare Advantage plan requirements.
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Track and report on coding quality metrics, HCC capture rates, and risk adjustment performance trends to clinical and operational leadership.
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Identify opportunities for process improvement related to risk adjustment documentation and coding workflows, and lead structured improvement initiatives.
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Stay current on CMS HCC model updates, Medicare Advantage coding guidelines, and regulatory changes affecting risk adjustment; proactively communicate relevant changes to the team.
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Support preparation for coding audits, RADV (Risk Adjustment Data Validation) reviews, and compliance activities as needed.
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Provide targeted coding and documentation guidance specific to the clinical workflows and patient populations within each of Avail's core care programs.
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Support alignment between CDA, HRA, and ICP documentation requirements and risk adjustment coding capture to ensure program integrity and compliance.
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Collaborate with care program managers and clinical leads to embed coding best practices into program design, clinician onboarding, and ongoing quality oversight.
Benefits
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Fully remote/work from home supporting a fully distributed team across the US.
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This is a fractional / part-time independent contractor (1099) engagement.
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Hours and scope are flexible and will be defined collaboratively based on Avail Health's program needs.
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Anticipated commitment ranges from 5 to 20 hours per week depending on program maturity, project phases, and organizational priorities.
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Compensation will be commensurate with experience and engagement scope.
