Quality Assurance Auditor

Job Description

Quality Assurance Coder/Auditor

Job Summary

Develop and support risk mitigation and provider education programs focused on accurate medical record documentation, HCC coding, risk adjustment, and identification of at-risk diagnoses. Review and analyze medical records, clinical diagnoses, procedures, injuries, and illnesses to recommend accurate and compliant coding practices.

Perform risk mitigation analysis using available vendor tools to identify unsupported HCCs and OIG targets. Submit deletions for invalid or unsupported diagnoses and use quality assurance findings and claims errors to guide provider education. Review medical records, abstract codes to the highest supported specificity, validate qualifying face-to-face encounters, and audit supplemental HCC data submissions.

Responsibilities

• Educate primary care providers and staff on historical diagnosis and coding trends, medical record documentation, at-risk codes, and risk mitigation.
• Review medical records and supporting documentation to determine completeness, accuracy, and appropriate coding.
• Identify documentation barriers and recommend coding improvements and best practices.
• Validate encounters, including face-to-face requirements, legibility, valid signatures, and Medicare Managed Care requirements.
• Perform quality assurance audits of vendor and provider group supplemental data submissions.
• Provide corrective action recommendations when accuracy scores fall below 95%.
• Track quality assurance audits and provide management updates regarding findings, healthcare gaps, documentation, coding, and education needs.
• Develop provider and coder education programs, training materials, and educational content.
• Prepare and deliver educational presentations through virtual meetings.
• Correct encounter rejections within vendor platforms.
• Maintain current knowledge of Medicare Managed Care risk adjustment requirements and outpatient billing processes.
• Maintain required coding certifications and stay informed about changes in risk adjustment methodologies.
• Perform other duties as assigned.

Requirements

• At least five years of professional coding experience, including three years of HCC coding and two years of HCC auditing experience.
• Advanced knowledge of coding guidelines.
• High school diploma or GED.
• One of the following certifications: Certified Coding Specialist Physician Based (CCS-P), Certified Risk Adjustment Coder (CRC), Certified Professional Coder (CPC), or Certified Outpatient Coding (COC).
• Preferred experience with Medicare Advantage health plans.
• Preferred experience with HEDIS measures and/or the CMS Star Program.
• Preferred clinical training as a Medical Assistant, Registered Nurse, Licensed Practical Nurse, or Certified Nursing Assistant.
• Preferred RHIT or RHIA credential.
• Preferred CDEO or CPMA certification.

Skill

• Comprehensive understanding of HCC coding rules, regulations, methodologies, and hierarchies.
• Strong knowledge of the CMS crosswalk between ICD diagnosis codes and HCC codes.
• Knowledge of anatomy, pathophysiology, medical terminology, CMS requirements, and ICD-10 coding guidelines.
• Knowledge of Medicare Managed Care risk adjustment requirements.
• Strong written and verbal communication skills.
• Ability to develop training materials and deliver provider education.
• Ability to identify and communicate documentation and coding deficiencies effectively.
• Proficiency with Microsoft Word, PowerPoint, and Excel.
• Ability to learn organizational systems and software applications.
• Knowledge of primary care office practices, electronic and manual medical records, and billing processes.
• Preferred understanding of the Risk Adjustment Validation Audit process.
• Preferred knowledge of pharmacology.

Summary Qualification

• Experienced medical coder and auditor with strong HCC and risk adjustment expertise.
• Skilled in medical record review, code validation, supplemental data auditing, and risk mitigation.
• Qualified to educate providers and staff on documentation, coding accuracy, and healthcare gap closure.
• Knowledgeable about Medicare Managed Care requirements, HCC hierarchies, ICD-10 coding, and CMS risk adjustment models.
• Strong analytical, communication, documentation, presentation, and quality assurance skills.

Wollborg Michelson Recruiting is an Equal Opportunity Employer and prohibits discrimination of any kind. We ensure job offers are made based of one s employment experience, skills, and qualifications, regardless of race, gender, ethnic origin, or any other classification protected by law. All applicants must furnish proper identification to prove their legal right to work in the US upon a job offer. We participate in E-Verify to confirm one s right to work in the US. Wollborg Michelson Recruiting does not provide sponsorship for an employment-based visa status.