Supervisor, Risk Adjustment Quality Assurance and Auditing

Excellus BCBS•Buffalo, NY

26d•Hybrid

About The Position

The Supervisor, Risk Adjustment Quality Assurance and Auditing, is responsible for oversight of the daily operations of the Risk Adjustment Quality Assurance Auditor team. This role ensures the accuracy, compliance, and quality of the risk adjustment coding and documentation audits in alignment with regulatory requirements and organizational policies. This position provides leadership, training, and performance management to audit staff while driving continuous improvement in audit processes, coding accuracy, and operational efficiencies. The Supervisor partners with leadership on developing strategies to enhance efficiency and quality practices and to prioritize all internal, state, and federal government audits (CMS Improper Payment Measure (IPM), Contract-level Risk Adjustment Data Validation (CON RADV), and Department of Health and Human Services (HRADV) and auditor workflow.

Requirements

Five (5) years ICD-10-CM and Hierarchical Condition Category (HCC) coding experience required and experience in CMS and HHS Risk Adjustment Data Validation Audits (RADV and HRADV).
Prior experience supervising or managing people and/or projects or indirectly leading teams.
CPC and CRC certifications required.
Advanced knowledge of medical terminology, abbreviations, anatomy and physiology, major disease processes, and pharmacology.
Knowledge of healthcare industry.
Extensive knowledge of coding conventions and payment rules as they apply to medical record documentation, billing of medical services, and health care reimbursement systems. This includes a comprehensive understanding of ICD-10, and other types of coding submitted to the Health Plan by contracted facilities, and providers.
Possess extensive knowledge of CMS and HHS HCC Risk Adjustment coding, Medicaid CRG coding, and data validation requirements.
Strong written and verbal communication skills; strong analytical, organization and time management skills required.
Recognizes and properly oversees confidential health information.
Demonstrated ability to utilize a variety of Electronic Medical Records (EMR) systems.
Demonstrated experience in project completion, educational program development, and/or group presentation.

Nice To Haves

Associate’s degree in a health care related field preferred.
Other current coding certification (CPC-H, CPC-I, CCS, RHIA, or RHIT) preferred by AAPC or AHIMA.
Certified Documentation Expert Outpatient (CDEO) preferred.

Responsibilities

Provide strategic oversight, supervision, and support to a team of Risk Adjustment Quality Assurance Auditors, ensuring all audit activities strictly adhere to state, federal, and corporate standards.
Direct and coordinate the day‑to‑day operations of the Risk Adjustment QA Audit team, ensuring coding accuracy, regulatory compliance, and consistent application of CMS, ICD‑10‑CM, and organizational guidelines.
Oversee risk adjustment audit activity including monthly internal coding quality audits and all federal and state risk adjustment data validation audits including, but not limited to, Improper Payment Measure, Contract-level RADV, Department of Health and Human Services RADV (HRADV).
Documents and defines audit project expectations and parameters for the Risk Adjustment Quality Assurance Auditors in keeping with department, corporate, state, and federal deadlines.
Assists the Risk Adjustment Coding Educator Manager and Training Lead in identifying areas of opportunity for external business partners and internal coding and audit staff for coding and audit education based on internal quality assurance and state and federal audits.
Provides coaching, mentoring, and ongoing training to audit staff to enhance coding knowledge and audit performance.
Conducts performance evaluations, goal setting, and regular feedback conversations via quarterly check-ins.
Ensure audits are conducted in accordance with CMS guidelines, ICD10-CM Official Coding Guidelines, risk adjustment coding standards, and organizational policies.
Monitor audit quality, accuracy rates, and turnaround times.
Assist in review of complex cases, as necessary.
Serves as a subject matter expert for Risk Adjustment Audit and Coding.
Advises staff on proper audit and coding practices through informal discussion and project validation.
Evaluates day-to-day workload and processes to maximize productivity and efficiency ensuring all deadlines are met.
Assists leadership verifying and reporting staff productivity, quality and assigning audit due dates, setting project expectations, and monitors staff for timely project completion.
Develops corrective action plans, training material, and performs training as needed.
Maintains staff and departmental quality and volume related statistics and provides documentation to departmental management.
Functions as a backup quality assurance auditor for risk adjustment audit functions and assists with day-to-day work as needed.
Executes audit projects in support of the Risk Adjustment Department strategy.
Identifies and recommends the development of new processes, as necessary.
Continually seeks and suggests process improvements to drive audit accuracy and productivity.
Coordinates and performs all RADV audits and other audits as requested.
Keeps management informed of project activities through regular written and oral status reports.
Proactively identifies risks that may hinder audit success.
Reports to the Manager Risk Adjustment Coding and Auditing on team and individual audit accomplishments, barriers, progress, and training needs.
Consistently demonstrates high standards of integrity by supporting the Lifetime Healthcare Companies’ mission and values, adhering to the Corporate Code of Conduct, and leading to the Lifetime Way values and beliefs.
Maintains high regard for member privacy in accordance with the corporate privacy policies and procedures.
Maintains knowledge of all relevant legislative and regulatory mandates and ensures that all activities are in compliance with these requirements.
Conducts regular staff meetings to include timely distribution and education related to departmental and Ethics/Compliance information.
Regular and reliable attendance is expected and required.
Performs other functions as assigned by management.