Senior Risk Adjustment Auditor

This is a fully remote position, open to applicants in United States.

📋 Description

• Conduct audits on third-party vendor coding and CDI outputs to verify accuracy, compliance, and adherence to established performance standards.

• Review the work of internal CDI Specialists I and II, including chart assessments, queries, and reconciliation tasks.

• Identify inaccuracies in coding, unsupported diagnoses, missed HCC opportunities, and documentation deficiencies.

• Present audit findings, trend analyses, and corrective action recommendations to CDI leadership and vendor partners.

• Monitor and report audit performance metrics to facilitate continuous quality improvement initiatives.

• Assess completed encounters during the post-visit, pre-billing phase to ensure documentation completeness and coding precision.

• Review and audit coding and CDI for Pre-visit plans.

• Evaluate the consistency between medical record documentation and draft claims to ensure proper HCC capture.

• Assess each diagnosis for compliance with ICD-10-CM specificity and MEAT criteria.

• Prioritize high-impact conditions and risk-adjustable diagnoses for timely intervention and resolution.

• Ensure compliant query practices that align with AHIMA and ACDIS standards.

• Review the quality of queries, provider responses, and documentation updates to confirm clinical support for diagnoses.

• Validate the final alignment between documentation and submitted claims, addressing discrepancies in collaboration with coding and billing teams.

• Convert audit findings into targeted educational resources for providers and their teams regarding documentation, coding specificity, and risk adjustment compliance.

• Collaborate with CDI, coding, and leadership teams to enhance workflows, policies, and audit preparedness.

• Act as a subject matter expert and resource on risk adjustment, CDI best practices, and auditing standards.

• Support the advancement of CDI and audit processes as automation, EMR integrations, and vendor models evolve.

• Identify opportunities to broaden audit scope, such as documentation trends, provider performance patterns, and process inefficiencies.

• Contribute to the creation of scalable audit frameworks and quality assurance methodologies.

• Provide real-time and aggregate feedback on coding and documentation to providers and their clinical support teams.

• Design and lead educational sessions on ICD-10-CM specificity, chronic condition documentation, HCC coding, and risk adjustment compliance, both virtually and, occasionally, in person.

• Perform other related duties as assigned.

⛳️ Requirements

• Associate’s or Bachelor’s degree in Health Information Management, Nursing, or a related clinical field (or equivalent experience).

• Minimum of 5 years of experience in risk adjustment, medical coding, CDI, or auditing.

• At least 2 years of experience in prospective and concurrent review risk adjustment coding and auditing.

• Direct experience with Medicare Advantage (Part C) risk adjustment models and HCC coding is mandatory.

• Experience in auditing vendor-delivered work and/or CDI programs is preferred.

• One or more of the following certifications: CRC (Certified Risk Adjustment Coder) and CPC (Certified Professional Coder) are essential.

• CCS (Certified Coding Specialist) or CCDS (Certified Clinical Documentation Specialist) is preferred.

• RHIT/RHIA certification is preferred.

• Advanced understanding of ICD-10-CM Official Guidelines and AHA Coding Clinic guidance.

• Advanced technical skills in risk adjustment and coding compliance.

• Comprehensive understanding of CMS risk adjustment methodologies and HCC models.

• Expertise in MEAT criteria application and compliant query practices.

• Familiarity with CDI workflows, EMR systems, and coding/audit tools.

• Strong analytical abilities to identify patterns, risks, and areas for improvement.

• High attention to detail and a strong commitment to accuracy and compliance.

• Ability to collaborate effectively with CDI, coding, vendor management, and provider teams.

• Capacity to translate complex audit findings into clear, actionable insights.

• Effective communication and collaboration skills with both clinical and non-clinical stakeholders.

• Ability to manage multiple priorities in a fast-paced, dynamic environment.

• Ability to work independently in a remote setting.

• Willingness to travel up to 25% for provider education or team collaboration.

• Commitment to maintaining confidentiality and adherence to all regulatory requirements.

🏝️ Benefits

• Eligible for short-term incentives.

• Comprehensive benefits package.