Auditor, Risk Adjustment

About the role:

The Associate, Risk Adjustment Auditor conducts internal and external quality audits. Quality audits are specific to ICD-10 code abstraction relative to accuracy, completeness, and identified clinical documentation improvement opportunities. You will work with management to implement benchmarks, establish acceptable thresholds, and quality assurance programs.

You will report into the Manager, Risk Adjustment.

Responsibilities:

• Responsible for daily operations pertaining to Risk Adjustment including but not limited to: 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.