Quality Assurance Risk Adjustment Auditor I/II

Cambia Health Solutions • Salt Lake, UT

11d • Hybrid

About The Position

Risk Adjustment Auditor performs Retrospective/Prospective chart review utilizing various types of records to ensure accurate risk adjustment reporting. Responsible for assisting in second level reviews of all new HCCs identified through the first pass chart review process. Identifies trends in provider coding/documentation and vendor risk adjustment reporting and makes those trends known to leadership as well as coding team manager and training lead to develop intervention strategies – all in service of creating a person-focused health care experience.

Requirements

• Associate degree in Healthcare or related field and one year of experience in clinical coding or auditing or equivalent combination of education and experience (for Auditor I).
• Associate degree in Healthcare or related field and three years of experience in clinical coding or auditing or equivalent combination of education and experience (for Auditor II).
• 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 (for Auditor II).
• Advanced knowledge and understanding of risk adjustment, coding and documentation requirements (for Auditor II).
• Demonstrated ability to provide proactive and creative solutions to business problems (for Auditor II).

Nice To Haves

• Candidates must reside within commutable distance of that location.
• 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

What This Job Offers

• Job Type: Full-time
• Career Level: Entry Level
• Education Level: Associate degree