Risk Adjustment - Risk Adjustment Auditor 135-2032

Community Care•Tulsa, OK

18h

About The Position

The Risk Adjustment Auditor reviews medical records and related documentation to ensure diagnoses are accurately captured in accordance with CMS risk adjustment guidelines, ICD-10-CM coding standards, and applicable payer-specific guidelines. The role supports accurate risk score calculation, regulatory compliance, and program integrity through retrospective and prospective record reviews, audit reporting, and collaboration with coding staff, providers, and operations teams. The auditor identifies unsupported diagnoses, over-coding, under-coding, and documentation gaps; provides findings and recommendations; monitors compliance with CMS Risk Adjustment Data Validation (RADV) standards; and tracks audit trends and performance metrics. The role also assists with education and training on risk adjustment and documentation best practices, maintains confidentiality in accordance with HIPAA, and meets productivity and quality standards set by the supervisor.

Requirements

A minimum of two years of risk adjustment coding or auditing experience.
Experience reviewing medical records across multiple specialties.
Certified Professional Coder (CPC), CRC, CCS, or equivalent coding certification.
Knowledge of CMS-HCC and HHS-HCC risk adjustment models.
Knowledge of ICD-10-CM coding guidelines.
Knowledge of RADV requirements.
Proficiency in EMR systems and Microsoft Office; Excel preferred.
High attention to detail.
Strong analytical and critical thinking skills.
Clear written and verbal communication.
Ability to work independently and meet deadlines.
Strong organizational skills.
Integrity and commitment to compliance.
Successful completion of a Health Care Sanctions background check.

Nice To Haves

Bachelor’s degree in Health Information Management or a related field.
Previous auditing experience in Medicare Advantage and ACA.
Experience with internal audit programs or payer audits.

Responsibilities

Perform bi-directional retrospective and prospective medical record reviews to validate, clarify, and accurately capture risk-adjusted diagnoses (HCCs) in accordance with CMS guidelines and MEAT documentation requirements.
Ensure documentation supports coded conditions in accordance with ICD-10-CM, CMS, and payer-specific guidelines.
Identify unsupported diagnoses, over-coding, under-coding, and documentation gaps.
Provide detailed audit findings and recommendations to coding teams, providers, and leadership.
Monitor compliance with CMS Risk Adjustment Data Validation (RADV) standards.
Track and report audit results, trends, and performance metrics.
Collaborate with coding staff, providers, and operations teams to improve documentation quality and coding accuracy.
Assist with education and training initiatives related to risk adjustment and documentation best practices.
Maintain confidentiality and ensure compliance with HIPAA regulations.
Meet daily and weekly productivity goals and quality standards set by the supervisor.
Perform other job-related duties as required or assigned.