When you join the growing BILH team, you're not just taking a job, you’re making a difference in people’s lives.
This role supports a clinically integrated network of providers and care teams committed to delivering high-quality, value-based care. The CDI Risk Adjustment Nurse plays a critical role in improving risk adjustment accuracy, documentation integrity, and gap closure performance across the network. This position leverages clinical expertise to conduct chart review and abstraction, identify coding opportunities, validate diagnoses, and support provider workflows, with a strong emphasis on chronic condition capture and pre-visit planning integration. Working under the direction of the CDI Manager and Performance leadership, this role collaborates across coding, quality, and provider teams to ensure accurate representation of patient complexity and to drive performance in value-based contracts.Job Description:
Essential Duties & Responsibilities including but not limited to:
Under the supervision of the CDI Manager, the CDI Risk Adjustment Nurse will: 1. Chart Review, Abstraction & Risk Gap Identification · Perform prospective, concurrent, and retrospective chart reviews to identify documentation and coding opportunities for risk adjustment · Abstract clinical data to support HCC/risk score accuracy and gap closure initiatives · Identify missed or undocumented chronic conditions, ensuring alignment with clinical evidence and documentation standards · Apply MEAT criteria (Monitor, Evaluate, Assess, Treat) to validate coding appropriateness · Identify trends and recurring documentation opportunities through chart review activities and communicate findings to CDI leadership to support provider education and performance improvement initiatives. 2. Coding Opportunity Identification & Pre-Visit Workflow Support · Identify coding opportunities as directed by the CDI Manager and Performance Director, with a focus on chronic disease burden · Partner with pre-visit planning and coding teams to: o Surface suspect conditions prior to encounters o Integrate findings into workflows and registries o Support timely risk gap closure
o Contribute to standardized processes that scale prospective coding workflows across a large provider network 3. Provider & Care Team Support · Act as a clinical advisor to providers and care teams, using nursing expertise to: o Recommend appropriate documentation for risk-adjusted conditions o Clarify clinical accuracy of diagnoses o Support interpretation of coding guidelines · Develop and deliver provider education related to clinical documentation improvement, risk adjustment, chronic disease documentation, and value-based care initiatives through individual coaching, group presentations, and educational materials. · Support real-time or pre-visit decision-making to optimize risk capture · Serve as a clinical resource for escalated documentation, coding, and clinical validation questions from providers, coding teams, and operational leadership. 4. Clinical Validation & Documentation Integrity · Serve as a clinical validation resource to ensure diagnoses are: o Clinically supported o Accurately documented o Compliant with coding and payer requirements · Collaborate with CDI and coding teams to resolve discrepancies and prevent denials · Ensure documentation supports audit defensibility and regulatory compliance · Identify patterns of clinical validation concerns, documentation deficiencies, and audit vulnerabilities and communicate findings to CDI leadership to support education and process improvement efforts. · 5. Audit & Quality Assurance · Conduct chart audits of coding outputs to validate accuracy and completeness · Identify trends, gaps, and opportunities for improvement in coding and documentation · Provide feedback and education to coding teams and providers based on audit findings · Monitor performance and compliance with established documentation standards 6. Collaboration & Program Support · Collaborate with CDI, coding, quality, population health, and physician leadership teams to support risk adjustment, quality, and value-based care initiatives. · Partner with the ACMO and physician leaders on quality improvement projects, including chronic disease management, preventive care, and care gap closure efforts. · Conduct clinical reviews and analyses to support patient identification, provider education, workflow optimization, and performance improvement initiatives. · Participate in committees, audits, and payer-related initiatives supporting organizational quality and risk adjustment goals.
Organizational Requirements:
Maintain strict adherence to all BILH and BILHPN Policies. Maintain courteous and effective interactions with colleagues and providers and stake holders. Demonstrate an understanding of the job description, performance expectations, and competency assessment. Demonstrate a commitment toward meeting and exceeding the needs of our customers and consistently adheres to customer service standards. Participate in departmental and/or interdepartmental quality improvement activities. Participate in and successfully completes Mandatory Education. Perform all other duties as needed or directed to meet the needs of the department.
Minimum Qualifications:
Education: Graduate of an accredited Registered Nurse (RN) program (Bachelor’s preferred)
Licensure, Certification & Registration: Active RN license in both MA and NH required
Experience: 3–5 years clinical experience; experience in CDI, risk adjustment, coding, or population health preferred
Skills, Knowledge & Abilities: Strong knowledge of risk adjustment (HCC), chronic condition documentation, EMRs, and coding principles; strong analytical, communication, and collaboration skills.
Pay Range:
$47,424.00 USD - $70,474.80 USDThe pay range listed for this position is the annual base salary range the organization reasonably and in good faith expects to pay for this position at this time. Actual compensation is determined based on several factors, that may include seniority, education, training, relevant experience, relevant certifications, geography of work location, job responsibilities, or other applicable factors permissible by law.