QA Risk ADj Auditor II

Cambia Health Solutions•Salt Lake, UT

5d•Hybrid

About The Position

This is a hybrid role for a Risk Adjustment Auditor I or II, with 3 days per week in the office, located in Salt Lake City, Boise, Fargo, Portland, Vancouver, Renton, Medford, Burlington, or Lewiston. The company prefers current employees and candidates who live within commuting distance of Salt Lake City, Boise, Fargo, and Lewiston, or are willing to relocate. The Risk Adjustment Auditor performs Retrospective/Prospective chart reviews using various records to ensure accurate risk adjustment reporting. This role is responsible for assisting in second-level reviews of all new HCCs identified through the first-pass chart review process. The auditor identifies trends in provider coding/documentation and vendor risk adjustment reporting, communicating these trends to leadership, the coding team manager, and the training lead to develop intervention strategies, all aimed at creating a person-focused healthcare experience. This role is ideal for someone who thrives in a collaborative, caring team environment.

Requirements

Associate degree in Healthcare or related field and three years of experience in clinical coding or auditing or equivalent combination of education and experience.
Risk Adjustment, HCC or Inpatient coding experience required.
CPC and CRC coding certification required.
Demonstrated ability to perform accurate and complete chart reviews for risk adjustment.
Demonstrated ability to perform quality audits of internal and vendor coding.
Knowledge of and adherence to Official ICD-9-CM/ICD-10 Coding Guidelines.
Demonstrated analytical ability to identify problems, develop solutions, and implement actions in a timely manner.
Demonstrated ability to identify and communicate trends in provider and vendor coding and documentation.
Demonstrated proficient PC skills and familiarity with corporate software, such as Word, Excel and Outlook.
Effective verbal and written communication skills.
Knowledge of health systems operations, including an understanding of reimbursement methodologies and coding conventions for governmental and commercial products.
Advanced knowledge and understanding of risk adjustment, coding and documentation requirements.
Demonstrated ability to provide proactive and creative solutions to business problems.

Nice To Haves

Experience with AI tools and technologies to enhance productivity and decision-making in professional settings highly desired.

Responsibilities

Performs Retrospective and Prospective chart reviews to ensure accurate risk adjustment reporting.
Performs quality reviews of vendor coding in support of the risk adjustment process.
Verifies and ensures the accuracy, completeness, specificity, and appropriateness of provider-reported diagnosis codes based on medical record documentation.
Reviews medical record information to identify complete and accurate diagnosis code capture based on CMS HCC and HHS HCC categories.
Identifies trends in provider and vendor coding and documentation and partners with coding team manager and training lead to develop intervention strategies.
Supports and actively participates in process and quality improvement initiatives.
Maintains knowledge of relevant regulatory mandates and ensures activities are in compliance with requirements.
Consistently meets departmental performance and attendance requirements.
Serves as a mentor to Risk Adjustment Auditor I staff.
Assists with special projects such as risk mitigation reviews.
Serves as subject matter resource regarding the risk adjustment process and diagnosis coding for risk adjustment.
Monitors and interprets regulatory changes that may impact administration of the Risk Adjustment Program.
Assists with implementation activities as a result of regulatory changes to the Program.

Benefits

Medical, dental and vision coverage for employees and their eligible family members, including mental health benefits.
Annual employer contribution to a health savings account.
Generous paid time off varying by role and tenure in addition to 10 company-paid holidays.
Market-leading retirement plan including a company match on employee 401(k) contributions, with a potential discretionary contribution based on company performance (no vesting period).
Up to 12 weeks of paid parental time off (eligibility requires 12 months of continuous service with Cambia immediately preceding leave).
Award-winning wellness programs that reward you for participation.
Employee Assistance Fund for those in need.
Commute and parking benefits.
Competitive base pay
Market-leading 401(k) with a significant company match
Bonus opportunities