Risk Adjustment Auditor
Job Summary
The Associate, Risk Adjustment Auditor conducts internal and external quality audits to ensure accurate ICD-10 code abstraction and clinical documentation improvement. This role involves implementing quality benchmarks and assurance programs while reporting to the Manager of Risk Adjustment. The position is remote-based with potential for occasional travel for team meetings.
Responsibilities
- Perform medical record reviews for ICD-10-CM coding
- Conduct quality audits and RADV activities
- Monitor Risk Adjustment coding team performance
- Develop clinical documentation improvement resources
- Ensure compliance with CMS and HHS standards
Required Skills
- Bachelor's degree or equivalent experience
- CPC Certification
- 3+ years retrospective risk adjustment coding
- 1+ year quality auditing experience
- Knowledge of ICD-10-CM guidelines
Job Details
### Responsibilities:
- Responsible for daily operations pertaining to Risk Adjustment including: medical record reviews to report ICD-10-CM diagnosis codes for ACA and MA lines of business, potential Centers of Medicare & Medicaid Services (CMS), Health and Human Services (HHS) audits and medical record retrieval efforts.
- Mitigate risk by validating Encounter Data Gathering Environment Server (EDGE) data is supported within provider encounter documentation.
- Review the performance of the Risk Adjustment Coding team and report audit trends to Leadership in a timely, consistent and effective manner to ensure the appropriate changes and education are implemented.
- Maintain compliance with national standards and coding practices set by the ICD-10-CM coding guidelines for accuracy, as well as compliance with Risk adjustment production standards.
- Conduct CMS audits of Risk Adjustment activities, including but not limited to Risk Adjustment Data Validation audits.
- Develop relationships with key individuals to foster an increased understanding of the Risk Adjustment process.
- Identify and execute on the creation of clinical document improvement resources for provider education in both MA and ACA line of business.
- Manage the implementation process improvements that will maximize risk adjustment factor increases.
- Compliance with all applicable laws and regulations.
- Other duties as assigned.
### Requirements:
- Bachelor's degree in a relevant field of study or commensurate work experience.
- Certified professional coder (CPC).
- 3+ year(s) retrospective risk adjustment coding experience.
- 1+ year(s) experience Quality Auditing and/or Risk Adjustment Data Validation Audit (RADV) experience.
### Bonus points:
- Certified Risk Adjustment Coder (CRC) or similar certification.
- Experience coding in a variety of different Electronic Medical Record (EMR) systems.