Risk Adjustment - Risk Adjustment Coding Auditor 135-2014

JOB SUMMARY:
The Risk Adjustment Auditor is responsible for reviewing medical records and related documentation to ensure accurate capture of diagnoses in compliance with CMS risk adjustment guidelines and ICD-10-CM coding standards. This role plays a critical part in supporting accurate risk score calculation, regulatory compliance, and overall program integrity.

KEY RESPONSIBILITIES:
•    Perform bi-directional retrospective and prospective medical record reviews to validate, clarify, and accurately capture risk adjusted diagnoses (HCCs) in accordance with CMS guidelines and MEAT documentation requirements.
•    Ensure documentation supports coded conditions in accordance with ICD-10-CM, CMS, and payer-specific guidelines.
•    Identify unsupported diagnoses, over coding, under-coding, and documentation gaps.
•    Provide detailed audit findings and recommendations to coding teams, providers, and leadership.
•    Monitor compliance with CMS Risk Adjustment Data Validation (RADV) standards.
•    Track and report audit results, trends, and performance metrics.
•    Collaborate with coding staff, providers, and operations teams to improve documentation quality and coding accuracy.
•    Assist with education and training initiatives related to risk adjustment and documentation best practices.
•    Maintain confidentiality and ensure compliance with HIPAA regulations.
•    Meet daily and weekly productivity goals and quality standards set by the supervisor.
•    Perform other job-related duties as required or assigned.

QUALIFICATIONS:
•    Knowledge of CMS-HCC and HHS-HCC risk adjustment model.
•    Knowledge of ICD-10-CM coding guidelines.
•    Knowledge of RADV requirements.
•    Proficiency in EMR systems and Microsoft Office (Excel preferred).
•    High attention to detail.
•    Strong analytical and critical thinking skills.
•    Clear written and verbal communication.
•    Ability to work independently and meet deadlines.
•    Strong organizational skills.
•    Integrity and commitment to compliance.
•    Successful completion of Health Care Sanctions background check.

EDUCATION/EXPERIENCE:
•    A minimum of two years of risk adjustment coding or auditing experience.
•    Experience reviewing medical records across multiple specialties.
•    Certified Professional Coder (CPC), CRC, CCS, or equivalent coding certification.
•    Bachelor’s degree in Health Information Management or related field preferred.
•    Previous auditing experience in Medicare Advantage and ACA preferred.
•    Experience with internal audit programs or payer audits preferred.