Senior Risk Adjustment Auditor – Health Plan

This is a fully remote position, open to applicants in South Dakota, +1 more state.

📋 Description

• Assist in achieving overall results and managing daily tasks for Risk Adjustment Data Validation (RADV) audits.

• Execute focused quality assurance audits.

• Supervise vendor quality assurance assessments.

• Carry out quality assurance for the internal coding team.

• Create, implement, and provide educational and training resources for providers and clinical staff.

• Utilize expertise in HCC documentation, audit regulations, risk adjustment processes, and clinical knowledge.

• Examine medical charts, claims, and enrollment data that support diagnosis codes submitted to government agencies.

• Detect quality issues within risk adjustment procedures through chart analysis, data investigations, and EMR proficiency.

• Conduct root cause analysis and communicate findings in a timely and organized manner.

• Present conclusions to providers, vendors, data teams, and senior leadership.

• Offer coding quality assurance and educational assistance for Medicare Advantage, ACA/Exchange, and Medicaid risk adjustment methodologies.

• Assist with internal monitoring and regulatory readiness efforts, including RADV and other compliance audits.

• Collaborate with department analysts on pertinent data operations.

• Undertake additional related responsibilities as assigned.

⛳️ Requirements

• Associate degree required; Bachelor’s degree is preferred.

• A minimum of 5 years of experience in HCC coding and auditing for Risk Adjustment.

• Intermediate knowledge of RADV protocols and procedures.

• Intermediate understanding of both retrospective and prospective risk adjustment.

• Basic proficiency in Microsoft Office Suite, including Excel.

• Familiarity with Epic or similar EHR systems preferred.

• Strong understanding of the CMS HCC model, its hierarchy, and relative HCC values.

• Certification as a Risk Adjustment Coder (CRC), Certified Professional Coder (CPC), or a relevant equivalent is required.

• An unencumbered RN license with the State Board of Nursing where nursing practice occurs and/or multistate licensure in an NLC state is preferred.

• Capability to obtain and maintain required department-specific competencies and certifications.

🏝️ Benefits

• Full-time work schedule.

• Day shift.

• 40 scheduled weekly hours.

• EEO/AA protections.

• Disability accommodation support during the application process.