Senior Risk Adjustment Auditor - Health Plan
About The Position
The Senior Risk Adjustment Auditor must have broad clinical knowledge and a strong understanding of Risk Adjustment operations, including experience coding for both the ACA and Medicare Advantage markets. This position will be responsible for overall outcomes and daily activities supporting Risk Adjustment Data Validation (RADV) audits, targeted quality assurance audits, vendor quality assurance oversight, internal coding team quality assurance, provider and clinical staff education, and other risk adjustment projects. Applies expertise in HCC documentation, audit rules, risk adjustment operations, and general clinical knowledge to increase the accuracy and completeness of our initiatives, including Risk Adjustment Data Validation (RADV) audits, retrospective and prospective audits, vendor quality assurance reviews, and provider and clinical staff education. Is accountable for the successful development, implementation and delivery of educational and training resource materials to assist providers in coding accuracy. Will work independently the majority of the time with a high degree of autonomy. This position will collaborate with department analyst(s) on relevant data operations. Reviews medical charts, claims, and enrollment data that support diagnosis codes reported on claims and submitted to governmental entities, with the goal of proactively identifying existing and potential quality issues in all our risk adjustment process. Seeks understanding through chart review, data investigations, and EMR expertise, while conducting root cause analysis, share findings in a timely and organized manner, and professionally presenting conclusions to a diverse audience, potentially including providers, vendors, data teams, and senior leaders. Provides overall educational support and coding quality assurance activities to both internal and external stakeholders as it relates to Medicare Advantage, ACA/Exchange and Medicaid risk adjustment reimbursement methodologies and policies to ensure the accuracy and integrity of risk adjustment data submitted to the Centers for Medicare & Medicaid Services (CMS) and the Department of Health Services (DHS). Trains others on best practices, guidelines and regulations of medical coding. Support internal monitoring and regulatory readiness activities, including Risk Adjustment Data Validation (RADV) and other regulatory audits Other related duties maybe be assigned.
Requirements
- Associate degree required, Bachelor’s preferred
- Minimum of 5 years HCC coding and auditing for Risk Adjustment required
- Intermediate understanding of RADV protocols and procedures
- Intermediate understanding of retrospective and prospective risk adjustment
- Basic familiarity with Microsoft suite, including Excel
- Strong knowledge of CMS HCC model, hierarchy, and relative HCC values required
- Certified Risk Adjustment Coder (CRC), Certified Professional Coder (CPC), or relevant equivalent is required
- Currently holds an unencumbered RN license with the State Board of Nursing where the practice of nursing is occurring and/or possess multistate licensure if in a Nurse Licensure Compact (NLC) state (preferred.)
- Obtains and subsequently maintains required department specific competencies and certifications.
Nice To Haves
- Working knowledge of Epic or similar EHR preferred
- Currently holds an unencumbered RN license with the State Board of Nursing where the practice of nursing is occurring and/or possess multistate licensure if in a Nurse Licensure Compact (NLC) state
Responsibilities
- Support Risk Adjustment Data Validation (RADV) audits
- Conduct targeted quality assurance audits
- Vendor quality assurance oversight
- Internal coding team quality assurance
- Provider and clinical staff education
- Manage other risk adjustment projects
- Develop, implement, and deliver educational and training resource materials to assist providers in coding accuracy
- Review medical charts, claims, and enrollment data
- Proactively identify existing and potential quality issues in all risk adjustment processes
- Conduct root cause analysis
- Share findings in a timely and organized manner
- Professionally present conclusions to a diverse audience
- Provide overall educational support and coding quality assurance activities to internal and external stakeholders
- Ensure accuracy and integrity of risk adjustment data submitted to CMS and DHS
- Train others on best practices, guidelines, and regulations of medical coding
- Support internal monitoring and regulatory readiness activities, including RADV and other regulatory audits
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What This Job Offers
Job Type
Full-time
Career Level
Senior
Education Level
Associate degree
