Risk Adjustment Coding Auditor

Risk Adjustment Coding Auditor

Location: Remote (U.S.)
Employment Type: Contract-to-Hire

About the Role

The Risk Adjustment Coding Auditor is responsible for ensuring the accuracy, completeness, and compliance of diagnosis coding used in risk adjustment programs. This role conducts prospective and retrospective chart audits, validates diagnosis code capture, identifies documentation opportunities, and provides coding guidance to support regulatory compliance and appropriate reimbursement. The auditor serves as a subject matter expert in risk adjustment coding and works closely with internal teams to maintain data integrity and reduce financial and regulatory risk.

Key Responsibilities

• Perform prospective and retrospective medical record reviews and audits.
• Validate diagnosis code accuracy, completeness, specificity, and appropriateness based on provider documentation.
• Review medical records to ensure proper capture of CMS-HCC diagnoses and risk adjustment opportunities.
• Audit risk adjustment records for compliance with ICD-10-CM coding guidelines and regulatory requirements.
• Identify coding and documentation deficiencies and provide written and verbal feedback.
• Support RADV, risk mitigation, and special audit projects.
• Maintain compliance with HIPAA, privacy, security, and regulatory standards.
• Meet productivity, quality, and audit performance expectations in a production environment.
• Serve as a subject matter expert on risk adjustment coding processes and coding guidelines.
• Collaborate with stakeholders to improve coding accuracy and documentation quality.

Required Qualifications

• 7+ years of relevant professional experience.
• 5+ years of HCC/Risk Adjustment coding experience utilizing inpatient and outpatient coding guidelines.
• 5+ years of Risk Adjustment auditing experience.
• 1+ year of experience working in a production-based environment.
• CRC (Certified Risk Coder) certification in good standing.
• Strong knowledge of Medicare, ACA Commercial, and Medicaid risk adjustment models.
• Experience applying ICD-10-CM coding guidelines and risk adjustment coding policies.
• Ability to interpret and implement coding regulations and compliance requirements.
• Experience providing coding education, audit feedback, and trend analysis.
• Intermediate proficiency with Microsoft Office Suite (Excel, Word, PowerPoint, and Outlook).
• Excellent organizational, analytical, and time management skills.
• High School Diploma or equivalent.
• Authorization to work in the United States without sponsorship.

Preferred Qualifications

• Bachelor's degree in Health Information Management, Healthcare Administration, or a related field.
• HEDIS and/or STAR Ratings experience.
• Provider education and training experience.
• Prior RADV auditing experience.
• Additional coding credentials such as CPMA, CPC, CCS, RHIA, or RHIT.