Auditor, Risk Adjustment

Oscar Health•Arizona, United States, AZ

9h•$82,717 - $108,566•Remote

About The Position

Oscar is hiring an Associate, Risk Adjustment Auditor to join their Risk Adjustment team. Oscar is a health insurance company that utilizes a full stack technology platform and focuses on serving its members. The Associate, Risk Adjustment Auditor will conduct internal and external quality audits, specifically focusing on ICD-10 code abstraction for accuracy, completeness, and identifying clinical documentation improvement opportunities. This role will collaborate with management to implement benchmarks, establish acceptable thresholds, and develop quality assurance programs.

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

Nice To Haves

Certified Risk Adjustment Coder (CRC) or similar certification
Experience coding in a variety of different Electronic Medical Record (EMR) systems.

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