Actuarial Jobs in Rochester, NY

Mercor is working with a leading AI research lab to improve the capabilities of next-generation AI systems. We are seeking experienced Risk Adjustment and HCC Coding leaders to evaluate AI tools designed to improve risk score accuracy and coding completeness in Medicare Advantage, Medicaid managed care, and ACA markets. Your expertise in hierarchical condition category (HCC) methodology, RADV audit preparation, and risk adjustment coding will directly shape AI systems that enhance documentation capture and risk score integrity. **Responsibilities** - Lead risk adjustment and HCC coding operations across Medicare Advantage, Medicaid, and/or ACA risk adjustment programs. - Evaluate AI-generated HCC coding assignments and risk adjustment recommendations for clinical accuracy and regulatory compliance. - Review medical records to ensure complete and accurate capture of HCC-eligible conditions supported by clinical documentation. - Conduct and oversee retrospective and prospective chart reviews for risk score optimisation. - Manage RADV (Risk Adjustment Data Validation) audit preparation and response processes. - Monitor risk adjustment KPIs including HCC capture rates, risk score accuracy, and chart retrieval rates. - Collaborate with clinical, coding, and compliance teams to improve documentation and coding for risk adjustment purposes. - Ensure compliance with CMS risk adjustment guidelines (RAPS, EDGE submissions) and Official Coding Guidelines. - Annotate AI outputs and provide structured coding feedback to support AI training datasets. **Requirements** - 5+ years of experience in risk adjustment coding, HCC coding, or Medicare Advantage coding operations, with at least 2 years in a leadership role. - Deep expertise in CMS-HCC, RxHCC, and/or ACA HHS-HCC risk adjustment methodologies. - Strong knowledge of ICD-10-CM coding guidelines as applied to HCC risk adjustment. - Experience with RADV audit preparation and CMS compliance requirements. - Familiarity with RAPS and EDGE submission processes. - Exceptional written and verbal English communication skills. - High attention to detail with the ability to identify coding inaccuracies and documentation gaps in AI-generated outputs. **Preferred Qualifications** - CRC (Certified Risk Coder), CCS, CPC, or RHIA credential. - Experience with risk adjustment analytics platforms and chart retrieval systems. - Background in health plan, Medicare Advantage organisation, or value-based care setting. - Familiarity with AI-assisted HCC coding tools and comfort evaluating AI-generated risk adjustment content. - Experience presenting risk adjustment performance to actuarial or executive teams. **Why Join?** - Contribute to the development of frontier AI systems in healthcare. - Collaborate with a world-class AI research organisation. - Gain exposure to cutting-edge AI workflows in risk adjustment and value-based care. - Opportunity to work on high-impact projects shaping the future of healthcare AI.