Risk Adjustment Auditor
Job Summary
The Associate, Risk Adjustment Auditor conducts internal and external quality audits focusing on ICD-10 code abstraction accuracy and clinical documentation improvement. This role involves working with management to implement quality benchmarks and assurance programs. The position is remote and requires periodic travel for team meetings.
Responsibilities
- Conduct internal and external quality audits
- Perform medical record reviews and ICD-10 coding
- Report audit trends and implement process improvements
- Ensure compliance with CMS, HHS, and ICD-10 standards
Required Skills
- Certified Professional Coder (CPC)
- 3+ years retrospective risk adjustment coding
- 1+ year Quality Auditing/RADV 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 CMS/HHS audits, and medical record retrieval.
- 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 to ensure appropriate changes and education are implemented.
- Maintain compliance with national standards and coding practices set by the ICD-10-CM coding guidelines and Risk adjustment production standards.
- Conduct CMS audits of Risk Adjustment activities, including Risk Adjustment Data Validation audits.
- Develop relationships with key individuals to foster 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 lines of business.
- Manage the implementation of process improvements that will maximize risk adjustment factor increases.
- Ensure compliance with all applicable laws and regulations.
Requirements:
- Bachelor's degree in a relevant field of study or commensurate work experience.
- Certified professional coder (CPC).
- 3+ years of retrospective risk adjustment coding experience.
- 1+ year of experience in Quality Auditing and/or Risk Adjustment Data Validation Audit (RADV).
Bonus points:
- Certified Risk Adjustment Coder (CRC) or similar certification.
- Experience coding in a variety of different Electronic Medical Record (EMR) systems.