Medicare Risk Adjustment Compliance Auditor (CPC, CCS, or CCS-P Required) (Remote)

Alignment Health•California Corporate Office, CA

7d•$64,384 - $96,577•Remote

About The Position

The Remote Risk Adjustment Compliance Auditor conducts provider- and coder-level reviews and audits to ensure accurate risk adjustment data is submitted to CMS. The role develops and maintains tracking tools, reviews audit outcomes and findings, and monitors corrective action plans resulting from reviews or audits. It monitors internal reporting for outliers, stays current with CMS audit processes, and actively participates in risk adjustment audits. The auditor works with Risk Adjustment Management on data validation and RADV coding audits, monitors coding accuracy and quality for internal staff and vendors, reviews IPA policies and procedures for compliance, and represents the department in RADV and other risk adjustment-related audits. The role also supports risk adjustment education, protects patient health information in accordance with HIPAA, and ensures compliance with applicable regulations and organizational standards.

Requirements

Minimum 3 years of professional coding experience in a medical group or health plan setting.
Bachelor’s degree in business administration, health care management, or a related field, or four additional years of experience in lieu of education.
Certified coder credential required: CPC, CCS, or CCS-P.
Experience with strategic planning in risk mitigation.
Ability to communicate positively, professionally, and effectively; provide leadership; teach; and collaborate.
Effective written and oral communication skills and ability to build constructive relationships with diverse members, management, employees, and vendors.
Ability to perform mathematical calculations and calculate simple statistics correctly.
Ability to prioritize multiple tasks and apply advanced problem-solving and reasoning to define problems, collect data, establish facts, draw conclusions, and design, implement, and manage resolutions.
Effective problem-solving, organizational, and time-management skills, and ability to work in a fast-paced environment.
Ability to comprehend and analyze statistical reports.
Ability to meet the job’s physical demands, including regularly talking or hearing, standing, walking, sitting, handling or feeling objects, tools, or controls, reaching with hands and arms, and frequently lifting or moving up to 10 pounds; close vision and ability to adjust focus are required.

Nice To Haves

Certified Auditor.
Previous use of Epic, Allscripts, or EZCap.
Experience with MS Access.

Responsibilities

Monitor coding prevalence reporting for coding outliers.
Review IPA policies and procedures to ensure programs are compliant.
Monitor internal coding staff accuracy percentages to ensure they are tracked and maintained.
Monitor coding vendor accuracy percentages to ensure coding accuracy and the quality of data submitted to CMS.
Work with Risk Adjustment Management on data validation and RADV coding audits to ensure submissions to CMS are complete and accurate.
Maintain a comprehensive tracking and management tool for Risk Adjustment Compliance.
Ensure compliance with applicable federal, state, and local regulations and institutional or organizational standards, practices, policies, and procedures.
Work with Risk Adjustment Management to monitor HCC Corrective Action Plans as needed.
Suggest customizations to Risk Adjustment education for support staff, PCPs, specialists, employees, contracted employees, and central departments.
Use, protect, and disclose patients’ protected health information only in accordance with HIPAA standards.
Maintain professional and technical knowledge through educational workshops, professional publications, personal networks, and professional societies.
Contribute to team efforts and accomplish related tasks as needed.
Represent the department in RADV and other risk adjustment-related audits.
Perform other duties as assigned to meet the organization’s needs.