Risk Adjustment - Risk Adjustment Coding Auditor

Location: Tulsa, Oklahoma, United StatesCompany: CommUnityCarePosted: 2026-10-06Risk Adjustment Auditor 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 include performing 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. Ensuring documentation supports coded conditions in accordance with ICD-10-CM, CMS, and payer-specific guidelines. Identifying unsupported diagnoses, over coding, under-coding, and documentation gaps. Providing detailed audit findings and recommendations to coding teams, providers, and leadership. Monitoring compliance with CMS Risk Adjustment Data Validation (RADV) standards. Tracking and reporting audit results, trends, and performance metrics. Collaborating with coding staff, providers, and operations teams to improve documentation quality and coding accuracy. Assisting with education and training initiatives related to risk adjustment and documentation best practices. Maintaining confidentiality and ensuring compliance with HIPAA regulations. Meeting daily and weekly productivity goals and quality standards set by the supervisor. Performing other job-related duties as required or assigned. Qualifications include 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 includes 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. CommunityCare is an equal opportunity at will employer and does not discriminate against any employee or applicant for employment because of age, race, religion, color, disability, sex, sexual orientation or national origin.