Risk Adjustment Coding Auditor

PacificSource Health Plans•Springfield, OR

1d•Hybrid

About The Position

The Risk Adjustment Coding Auditor reviews medical records to ensure accurate, compliant ICD 10 CM coding across Medicare Advantage, ACA/Commercial, and Medicaid programs. This role validates coding accuracy and specificity, audits external coding vendors, and provides feedback to improve documentation and coding performance. The auditor also leads ACA and Medicare Advantage RADV activities, ensuring timely retrieval, review, and submission of records in line with federal and state requirements.

Requirements

A minimum of 4 years of risk adjustment coding experience, including hands on HCC coding, is required.
Proficiency in coding directly from the ICD 10 CM code book is required.
Experience with different EMRs and medical records retrieval outreach activities is required.
Requires strong knowledge of HIPAA requirements and a consistent commitment to maintaining the privacy, security, and confidentiality of medical documentation.
Requires solid clinical understanding of chronic disease diagnosis, treatment, and management, along with extensive knowledge of ICD 10 CM outpatient coding guidelines.
Exceptional attention to detail, accuracy, and completeness, supported by strong analytical, organizational, interpersonal, and written and verbal communication skills.
Reliability and the ability to manage competing priorities and meet tight deadlines are essential.
High school diploma or equivalent required.
Active Certified Risk Adjustment Coder (CRC) and Certified Professional Medical Auditor (CPMA) certifications through AAPC are required.

Nice To Haves

Experience conducting coding audits and interpreting complex regulatory guidelines is highly preferred.
Prior experience working within a health insurance plan, health system, or large provider organization is preferred.
Experience developing or delivering coder or provider education is also desirable.
Bachelor’s degree preferred.

Responsibilities

Conduct retrospective and prospective medical record audits to ensure ICD 10 CM diagnosis codes are accurate, complete, specific, and supported by documentation.
Ensure all coding practices comply with CMS risk adjustment guidelines, ICD 10 CM Official Coding Guidelines, and AAPC/AHIMA standards.
Identify coding trends, documentation gaps, errors, and opportunities to improve risk score accuracy.
Validate clinical evidence supporting chronic condition coding to ensure proper documentation and submission.
Prepare detailed audit reports summarizing findings, error categories, trends, and recommendations for corrective action.
Provide clear, constructive feedback to coding teams, providers, and vendor partners based on audit outcomes.
Develop and deliver training materials, job aids, and educational sessions to address documentation and coding improvement areas.
Serve as a subject matter expert on risk adjustment coding best practices, documentation requirements, and regulatory updates.
Collaborate with internal teams including Risk Adjustment Operations, Coding, Compliance, Quality, and Provider Engagement.
Lead and execute ACA and Medicare Advantage RADV audits, including medical record retrieval, coding review, appeals support, and documentation submission to IVA and CMS portals.
Oversee coding vendors and In Home Assessment programs to ensure performance aligns with contractual SLAs.
Obtain medical records from provider Electronic Health Record (EHR) systems and coordinate remote EHR access for internal teams and chart review vendors.
Maintain audit documentation and support tracking of corrective action plans.
Participate in internal and external audits initiated by regulatory bodies, partners, or compliance teams.
Support the development and refinement of audit methodologies, tools, and internal risk adjustment processes.
Assist in updating organizational policies and procedures to ensure regulatory compliance.
Monitor changes in risk adjustment regulations and coding guidelines and incorporate required updates into internal practices.
Adhere to the Standards of Ethical Coding and all official coding guidelines.
Meet department and company performance and attendance expectations.
Follow the PacificSource privacy policy and HIPAA laws and regulations concerning confidentiality and security of protected health information.
Perform other duties as assigned.