Risk Adjustment Coding Auditor

Risk Adjustment Coding Auditor

The Risk Adjustment Coding Auditor ensures the accuracy and completeness of coded clinical data to support compliant reporting and appropriate reimbursement across risk adjustment programs. The role strengthens organizational performance by identifying coding and documentation gaps, mitigating financial and regulatory risk, and improving data integrity. It provides subject matter expertise to support consistent application of coding standards and enables informed decision-making across the enterprise.

Evaluates risk adjustment codes to ensure accuracy, consistency, and alignment with coding standards and best practices. Protects patient records and audit information by ensuring compliance with HIPAA, privacy, security, and regulatory requirements. Performs Retrospective and Prospective chart reviews to ensure accurate risk adjustment reporting. Verifies and ensures the accuracy, completeness, specificity and appropriateness of provider-reported diagnosis codes based on medical record documentation. Reviews medical record information to identify complete and accurate diagnosis code capture based on CMS HCC categories. Maintains knowledge of relevant regulatory mandates and ensures activities are in compliance with requirements. Contributes to audit and production efforts to meet business demand and workload priorities. Provide written and verbal guidance on coding errors to others. Meets audit deliverables within established timelines and deadlines. Assists with special projects such as risk mitigation reviews. Serves as subject matter resource regarding the risk adjustment process and diagnosis coding for risk adjustment.

7+ years of related professional experience. All relevant experience including work, education, transferable skills, and military experience will be considered. 5+ years of HCC coding experience in utilizing inpatient and outpatient coding guidelines. 5+ years of experience auditing Risk Adjustment records. 1+ years working in a Production environment CRC (Certified Risk Coder) in good standing, in addition to required coding certification or ability to obtain certification within the first 6 months of hire, upon possible conversion. Intermediate level of knowledge in risk adjustment Medicare, ACA Commercial and Medicaid models. Demonstrated ability to apply critical thinking skills to coding policy interpretation and implementation. Experience providing written and verbal guidance on coding errors and trends. Intermediate (or higher) MS Office (Word, Excel, Powerpoint & Outlook). Excellent organizational ability to manage multiple projects and perform in a deadline driven environment. High school diploma (or equivalency) and legal authorization to work in the U.S. Preferred skills and experiences include Bachelor's degree, HEDIS/STARS experience, Provider education experience, Prior RADV experience, CPMA or other coding credentials.