Auditor, Risk Adjustment

About the role

The Associate, Risk Adjustment Auditor conducts internal and external quality audits. Quality audits are specific to ICD-10 code abstraction relative to accuracy, completeness, and identified clinical documentation improvement opportunities. You will work with management to implement benchmarks, establish acceptable thresholds, and quality assurance programs.

Responsibilities

• Responsible for daily operations pertaining to Risk Adjustment including but not limited to: medical record reviews to report ICD-10-CM diagnosis codes for ACA and MA lines of business, potential Centers of Medicare & Medicaid Services (CMS), Health and Human Services (HHS) audits and medical record retrieval efforts.
• Mitigate risk by validating Encounter Data Gathering Environment Server (EDGE) data is supported within provider encounter documentation
• Review the performance of the Risk Adjustment Coding team and report audit trends to Leadership in a timely, consistent and effective manner to ensure the appropriate changes and education are implemented.
• Maintain compliance with national standards and coding practices set by the ICD-10-CM coding guidelines for accuracy, as well as compliance with Risk adjustment production standards.
• Conduct CMS audits of Risk Adjustment activities, including but not limited to Risk Adjustment Data Validation audits.
• Develop relationships with key individuals to foster an increased understanding of the Risk Adjustment process.
• Identify and execute on the creation of clinical document improvement resources for provider education in both MA and ACA line of business.
• Manage the implementation process improvements that will maximize risk adjustment factor increases.
• Compliance with all applicable laws and regulations
• Other duties as assigned

Requirements

• Bachelor's degree in a relevant field of study or commensurate work experience.
• Certified professional coder (CPC)
• 3+ year(s) retrospective risk adjustment coding experience.
• 1+ year(s) experience Quality Auditing and/or Risk Adjustment Data Validation Audit (RADV) experience

Bonus points

• Certified Risk Adjustment Coder (CRC) or similar certification
• Experience coding in a variety of different Electronic Medical Record (EMR) systems.

Pay, Benefits, and Schedule

The base pay for this role is: $82,717 - $108,566 per year You are also eligible for employee benefits, participation in Oscar's unlimited vacation program and annual performance bonuses.