Risk Adjustment Compliance Auditor (Remote)

Alignment Health • Remote CA Outside Bay Area, CA

5d • $64,384 - $96,577 • Remote

About The Position

Alignment Health is seeking a remote Risk Adjustment Compliance Auditor to support auditing and compliance activities related to risk adjustment data submitted to CMS. In this role, you will conduct provider and coder-level audits, review medical record documentation and coding accuracy, identify compliance risks and outliers, and support RADV and other risk adjustment audit initiatives. This position is ideal for an experienced certified coder with a strong understanding of risk adjustment, HCC coding, compliance auditing, and CMS guidelines within a health plan, IPA, or managed care environment. You will partner closely with Risk Adjustment leadership and cross-functional teams to help ensure coding accuracy, regulatory compliance, audit readiness, and corrective action follow-through across the organization. The role combines auditing, documentation review, reporting, compliance monitoring, and collaborative problem-solving in a fully remote environment. You will also help provide audit feedback and compliance education to internal and provider-facing stakeholders as needed.

Requirements

• Minimum 3 years of professional coding experience in a medical group or health plan setting.
• Certified Coder required - CPC, CCS & CCS-P.
• Experience with strategic planning in risk mitigation.
• Ability to communicate positively, professionally and effectively with others; provide leadership, teach and collaborate with others.
• Effective written and oral communication skills; ability to establish and maintain a constructive relationship with diverse members, management, employees and vendors.
• Ability to perform mathematical calculations and calculate simple statistics correctly.
• Ability to prioritize multiple tasks; advanced problem-solving; ability to use advanced reasoning to define problems, collect data, establish facts, draw valid conclusions, and design, implement and manage appropriate resolution.
• Effective problem solving, organizational and time management skills and ability to work in a fast-paced environment.
• Comprehend and analyze statistical reports.

Nice To Haves

• Previous use of Epic, Allscripts, EZCap a plus.
• Proficient user in MS office suite, MS access a plus.
• Certified Auditor.

Responsibilities

• Monitors coding prevalence reporting, internal reporting trends, and coding outliers to support compliance and audit readiness.
• Reviews IPA Policies and procedures to ensure programs are compliant.
• Monitors internal coding staff accuracy percentages to ensure they are tracked and maintained.
• Monitors coding vendor’s accuracy percentages to ensure the coding accuracy and quality of the data submitted to CMS.
• Works with Risk Adjustment Management on data validation and RADV coding audit activities, including review of audit outcomes, findings, completeness, and coding accuracy of submissions to CMS.
• Maintains and develops audit tracking, reporting, and management tools related to Risk Adjustment Compliance activities.
• Ensures compliance with all applicable federal, state & and local regulations, as well as institutional/organizational standards, practices, policies & procedures.
• Works with Risk Adjustment Management to monitor HCC corrective action plans and follow-up activities related to audit and review findings.
• Suggests customizations of Risk Adjustment education for support staff, PCPs, specialists, employees, contracted employees and central departments.
• Utilizes, protects, and discloses Alignment Healthcare patients’ protected health information (PHI) only in accordance with Health Insurance Portability and Accountability Act (HIPAA) standards.
• Maintains current knowledge of CMS audit processes, risk adjustment regulations, and industry best practices through ongoing education, professional development, and participation in relevant professional organizations.
• Contributes to team effort by accomplishing related results as needed.
• Represents and actively participates in RADV and other risk adjustment-related audits and compliance activities.
• Other duties as assigned to meet the organization’s needs.

Benefits

• Full-time, Monday – Friday
• Initial training schedule will align primarily with Pacific Time business hours
• Flexible working hours available post-training based on business needs and team collaboration

What This Job Offers

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