Risk Adjustment Coding Auditor

Clever Care Health Plan•Huntington Beach, CA

3d•$72,800 - $85,000•Hybrid

About The Position

The Risk Adjustment Coding Auditor conducts retrospective and prospective coding audits, diagnosis validation reviews, provider documentation assessments, and compliance monitoring to support accurate Medicare Advantage risk adjustment reporting and CMS audit readiness. The role reviews medical records and ICD-10-CM diagnosis coding for compliance with CMS Risk Adjustment program requirements, Official Coding Guidelines, AHA Coding Clinic guidance, and organizational policies. As a subject matter expert in HCC coding, diagnosis validation, provider documentation improvement, and risk adjustment compliance, this position supports enterprise risk adjustment initiatives through audit activities, RADV preparedness, chart review validation, vendor oversight, provider education, and continuous quality improvement. The goal is to improve coding accuracy, documentation integrity, and risk score accuracy. The position follows a hybrid schedule, with three days onsite at the Huntington Beach office when not visiting provider offices. Work is performed in an office environment and/or remotely, with travel as needed. Occasional irregular hours may be required based on business needs. A background check is required.

Requirements

Bachelor's degree in Health Information Management, Nursing, Healthcare Administration, Public Health, or a related discipline; an equivalent combination of education and experience may be considered.
At least five years of experience in Medicare Advantage Risk Adjustment, HCC coding, coding audits, compliance auditing, provider education, or related healthcare auditing functions.
At least three years of experience conducting risk adjustment coding audits and diagnosis validation reviews.
Demonstrated experience delivering provider documentation improvement and coding education.
Advanced knowledge of CMS Risk Adjustment methodology, ICD-10-CM coding guidelines, HCC models, and medical necessity documentation requirements.
At least one required certification: 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), or 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, including the ability to identify trends, root causes, and improvement opportunities.
Ability to interpret clinical documentation and apply coding guidelines consistently and accurately.
Excellent written and verbal communication skills, including the ability to present audit findings and education effectively 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.
Ability to work independently and collaboratively in a fast-paced, cross-functional environment.
Commitment to regulatory compliance, data integrity, confidentiality, and continuous quality improvement.
Must be able to travel when needed or required.
Ability to operate a keyboard, mouse, and phone; perform repetitive keyboard motions; and take written notes.
Ability to sit for long periods, stand, reach, bend, and lift up to 15 pounds.
Ability to express or exchange ideas, impart information to the public, and convey detailed instructions to staff accurately and quickly.
A background check is required.

Nice To Haves

Experience in a health plan, Medicare Advantage Organization (MAO), MSO, IPA, physician group, or risk-bearing entity.
Experience supporting CMS RADV audits, chart review programs, validation projects, or compliance monitoring activities.
Experience with risk adjustment, coding audit, EMR, and analytics platforms.

Responsibilities

Conduct retrospective, prospective, and targeted coding audits to assess ICD-10-CM coding accuracy, completeness, compliance, and HCC capture.
Review medical records to validate reported diagnoses and ensure compliance with 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 analyses concerning coding accuracy, documentation quality, chart retrieval, provider workflows, and vendor performance.
Support CMS RADV audit readiness, including chart validation reviews, mock audits, record retrieval, and documentation reconciliation.
Analyze coding, documentation, provider, and vendor performance data to identify trends, compliance risks, and audit findings.
Conduct focused reviews of high-risk HCCs, OIG-targeted conditions, and other elevated audit-risk areas.
Analyze audit outcomes and recommend improvements to coding accuracy, documentation quality, and compliance performance.
Develop and maintain audit methodologies, quality assurance protocols, audit tools, and compliance monitoring processes.
Educate providers and staff on risk adjustment coding, documentation best practices, diagnosis validation, and CMS compliance requirements.
Conduct provider meetings and onsite 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, 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.