Risk Adjustment Auditor Educator

Centene Corporation • Remote-NV, NV

2d • $56,200 - $101,000 • Remote

About The Position

The Risk Adjustment Auditor Educator conducts provider medical record audits, analyzes practice coding patterns and Medicare risk adjustment data, and provides education and training on risk adjustment. The role supports accurate CMS payment and improved quality of care by identifying patterns and developing provider- and market-level interventions. This is a remote role serving the Southern Nevada territory.

The position acts as a subject matter expert on risk adjustment coding and CMS data validation, working with Provider Relations, Quality, and the assigned state Medical Director to support compliance with CMS risk adjustment guidelines. It also performs quality assurance audits of Medical Coding Specialists’ work and contributes to audit requests and the RADV Committee.

Requirements

• Bachelor’s degree or equivalent experience.
• At least 5 years of experience in a hospital, physician setting, or Managed Care Organization as a medical coder.
• At least 2 years of coding experience with knowledge of Medicare risk adjustment (HCC coding).
• Teaching, training, or educator/instructor experience is required.
• One of the following certifications is required at the time of hire: CPC or CCS.
• CPMA certification is required within the first year of employment.
• CRC certification is required in the second year of employment.
• Ability to accurately evaluate diagnosis coding and determine whether documentation supports the reported code.
• Clear communication, strong organizational skills, and flexibility.

Nice To Haves

• Managed care experience.
• Provider education experience.
• Strong understanding of HCC methodology, risk-adjustable diagnoses, CMS requirements, and compliant diagnosis capture.
• Experience working with and educating providers around diagnosis codes.

Responsibilities

• Conduct provider medical record audits and analyze practice coding patterns.
• Analyze MRA data to identify patterns and develop interventions at provider and market levels.
• Coordinate an educational work plan for contracted WellCare providers.
• Conduct provider education and training on risk adjustment through provider offices, hospitals, webinars, conference calls, email, and other venues.
• Work with Provider Relations, Quality, and the assigned state Medical Director to ensure compliance with CMS risk adjustment guidelines.
• Work on additional risk adjustment audit requests, including requests from outside auditors.
• Serve as a subject matter expert on the RADV Committee.
• Perform quality assurance audits to ensure the appropriateness and accuracy of ICD-9/ICD-10 coding by Medical Coding Specialists.
• Communicate quality assurance results to Medical Coding Specialists and suggest improvements and re-training topics.
• Perform other duties as assigned and comply with all policies and standards.

Benefits

• Competitive pay.
• Health insurance.
• 401(k) and stock purchase plans.
• Tuition reimbursement.
• Paid time off and holidays.
• Flexible approach to work, with remote, hybrid, field, or office work schedules.
• Potential additional forms of incentives.

What This Job Offers

• Job Type: Full-time