Risk Adjustment Auditor

While maintaining strict confidence of private information, the Risk Adjustment Auditor is primarily responsible to evaluate the medical record abstraction and provider education completed by internal staff and/or external vendors for Medicaid and Medicare LOBs. Audits are performed in the office using electronically submitted records or accessing provider EMR Systems. The Auditor will interact with provider offices to request medical chart access for review. The Auditor documents the results of the qualitative review and provides feedback supporting rationale.
Ensure risk adjusted payment integrity and accuracy complies with CMS regulations for reporting valid HCC/CDPS diagnoses on our members.
This position will travel by motor vehicle to provider sites. Approximately 10% of the job activity is conducted at provider sites.
Education/ Experience:

• 5 to 10 years abstracting and coding medical record information in the professional provider setting for the purpose of billing government or commercial insurance carriers or in support of Risk Adjustment/HCC .
• Remain current on changes to or new coding guidelines. Reman current in all certifications via continuing education.
• High School/GED
• Associate's Degree Preferred
• Certification Required: CPC, CPMA or CCA/CCS-P or RHIA
• Documented ICD-10 Proficiency from an accredited organization required
• Risk Adjustment CRC and HCC experience required

• Proven audit skills and the ability to interpret and apply Federal and State regulations, coding and billing requirements
• Ability to provide feedback constructively and with sensitivity
• Demonstrated ability to identify coding trends and risk areas
• Demonstrated knowledge of CMS reimbursement methodologies, Hierarchical Condition or similar Risk Adjustment disease model categories
• Demonstrated knowledge of HEDIS and STAR Measure rating and criteria
• Excellent written, skills used to share audit findings
• Ability to work with and maintain confidentiality of provider, patient, patient account data
• Demonstrated critical thinking skills and ability to resolve complex coding issues and perform root cause analysis
• Must have experience with data entry into a database and/or software tool
• Must have experience with face to face provider education
• Must have demonstrated experience with ability to work independently.