Risk Adjustment Coding Auditor

Clever Care Health Plan•Huntington Beach, CA

3d•$72,800 - $80,000•Hybrid

About The Position

The Risk Adjustment Coding Auditor is responsible for conducting retrospective and prospective coding audits, diagnosis validation reviews, provider documentation assessments, and compliance monitoring activities to support accurate Medicare Advantage risk adjustment reporting and CMS audit readiness. This role reviews medical record documentation and ICD-10-CM diagnosis coding to ensure compliance with CMS Risk Adjustment program requirements, Official Coding Guidelines, AHA Coding Clinic guidance, and organizational policies. The Risk Adjustment Coding Auditor serves as a subject matter expert in HCC coding, diagnosis validation, provider documentation improvement, and risk adjustment compliance. The position supports enterprise risk adjustment initiatives through audit activities, RADV preparedness, chart review validation, vendor oversight, provider education, and continuous quality improvement efforts aimed at enhancing coding accuracy, documentation integrity, and risk score accuracy.

Requirements

Bachelor's degree in Health Information Management, Nursing, Healthcare Administration, Public Health, or a related discipline; equivalent combination of education and experience may be considered.
Minimum of five (5) years of experience in Medicare Advantage Risk Adjustment, HCC coding, coding audits, compliance auditing, provider education, or related healthcare auditing functions.
Minimum of three (3) years of experience conducting risk adjustment coding audits and diagnosis validation reviews.
Health plan, Medicare Advantage Organization (MAO), MSO, IPA, physician group, or risk-bearing entity experience strongly preferred.
Experience supporting CMS RADV audits, chart review programs, validation projects, or compliance monitoring activities preferred.
Demonstrated experience delivering provider documentation improvement (PDI) and coding education.
Advanced knowledge of CMS Risk Adjustment methodology, ICD-10-CM coding guidelines, HCC models, and medical necessity documentation requirements.
One of more of the following certifications are required: Certified Professional Coder (CPC), Certified Coding Specialist (CCS), Certified Coding Specialist–Physician-Based (CCS-P), Certified Risk Adjustment Coder (CRC), Certified Professional Medical Auditor (CPMA), Registered Health Information Technician (RHIT), Registered Health Information Administrator (RHIA)
Strong knowledge of CMS Risk Adjustment methodology, HCC coding models, ICD-10-CM coding guidelines, and Medicare Advantage regulations.
Expertise in diagnosis validation, medical record auditing, provider documentation review, and coding compliance.
Ability to accurately identify supported, unsupported, and insufficiently documented diagnoses.
Thorough understanding of M.E.A.T. criteria, clinical documentation requirements, and diagnosis reporting standards.
Knowledge of RADV audit methodologies, audit risk areas, and compliance monitoring practices.
Strong analytical, investigative, and critical-thinking skills with the ability to identify trends, root causes, and opportunities for improvement.
Ability to interpret clinical documentation and apply coding guidelines consistently and accurately.
Excellent written and verbal communication skills with the ability to effectively present audit findings and education to providers, vendors, and leadership.
Strong organizational and project management skills with the ability to manage multiple priorities and deadlines.
Proficiency in Microsoft Office Suite, including Excel, Word, PowerPoint, and Outlook.
Experience with risk adjustment, coding audit, EMR, and analytics platforms preferred.
Ability to work independently and collaboratively in a fast-paced, cross-functional environment.
Commitment to regulatory compliance, data integrity, confidentiality, and continuous quality improvement.

Responsibilities

Conduct retrospective, prospective, and targeted coding audits to assess the accuracy, completeness, and compliance of ICD-10-CM diagnosis coding and HCC capture.
Review medical record documentation to validate reported diagnoses and ensure adherence to CMS Risk Adjustment data submission requirements and M.E.A.T. documentation standards.
Perform diagnosis validation and deletion reviews to identify unsupported, inaccurately coded, or insufficiently documented conditions.
Conduct second-level quality assurance reviews and root cause analysis related to coding accuracy, documentation quality, chart retrieval processes, provider workflows, and vendor performance.
Support CMS RADV audit readiness activities, including chart validation reviews, mock audits, record retrieval efforts, and documentation reconciliation.
Identify trends, compliance risks, and audit findings through analysis of coding, documentation, provider, and vendor performance data.
Perform focused reviews of high-risk HCCs, OIG-targeted conditions, and other areas of elevated audit risk.
Analyze audit outcomes and develop actionable recommendations to improve coding accuracy, documentation quality, and compliance performance.
Develop and maintain audit methodologies, quality assurance protocols, audit tools, and compliance monitoring processes.
Deliver provider and staff education related to risk adjustment coding, documentation best practices, diagnosis validation, and CMS compliance requirements.
Conduct provider meetings and on-site or virtual educational sessions to review audit findings, documentation deficiencies, coding opportunities, and corrective actions.
Monitor vendor and provider audit performance and support corrective action plans, remediation efforts, and continuous improvement initiatives.
Collaborate with Risk Adjustment, Quality, Compliance, Provider Relations, Clinical Operations, and external partners to address coding and documentation issues.
Prepare audit reports, provider scorecards, compliance summaries, executive dashboards, and leadership presentations.
Serve as a subject matter expert on CMS Risk Adjustment methodology, HCC coding, RADV audits, documentation standards, and regulatory requirements.
Maintain current knowledge of CMS regulations, ICD-10-CM coding updates, risk adjustment methodology changes, audit trends, and industry best practices.
Perform other duties as assigned.