Auditor, Risk Adjustment

This is a fully remote position, open to applicants in Arizona, +2 more states.

📋 Description

• Oversee daily operations related to Risk Adjustment, which includes, but is not limited to, conducting medical record reviews to report ICD-10-CM diagnosis codes for ACA and MA business lines, and managing potential audits from the Centers for Medicare & Medicaid Services (CMS) and Health and Human Services (HHS), as well as medical record retrieval efforts.

• Reduce risk by ensuring that Encounter Data Gathering Environment Server (EDGE) data is accurately reflected in provider encounter documentation.

• Evaluate the performance of the Risk Adjustment Coding team and promptly report audit trends to Leadership to facilitate timely and effective changes and education.

• Ensure adherence to national standards and coding practices as outlined by the ICD-10-CM coding guidelines for accuracy and compliance with Risk Adjustment production standards.

• Perform CMS audits on Risk Adjustment activities, including but not limited to Risk Adjustment Data Validation audits.

• Build relationships with key stakeholders to enhance understanding of the Risk Adjustment process.

• Recognize and implement the development of clinical document improvement resources for provider education in both MA and ACA business lines.

• Oversee the execution of process improvements to maximize risk adjustment factor increases.

• Adhere to all relevant laws and regulations.

• Other responsibilities as assigned.

⛳️ Requirements

• Bachelor's degree in a relevant field or equivalent work experience.

• Certified Professional Coder (CPC) certification.

• A minimum of 3 years of retrospective risk adjustment coding experience.

• At least 1 year of experience in Quality Auditing and/or Risk Adjustment Data Validation Audit (RADV).

🏝️ Benefits

• Employee benefits.

• Participation in Oscar's unlimited vacation program.

• Annual performance bonuses.