HCC Coding Auditor Senior - Health Plan Network

About the role

The HCC Coding Auditor Senior will perform code audits and abstraction using the Official Coding Guidelines for ICD-10‑CM, AHA Coding Clinic Guidance, and in accordance with all state regulations, federal regulations, internal policies, and internal procedures. The role involves quality assurance auditing and risk adjustment code abstraction for programs such as Commercial Risk Adjustment, Medicare Advantage Risk Adjustment, and HHS/Medicare RADV. This is an onsite position with a remote option.

Responsibilities

• Perform medical record reviews and audits based on organizational priorities, including prospective, concurrent, and retrospective Clinical Documentation Improvement (CDI) workflows.
• Review and audit records to add, delete, adjust, or confirm diagnoses for risk adjustment.
• Conduct code abstraction and coding quality audits to ensure ICD‑10‑CM codes are accurately assigned and supported by clinical documentation, adhering to CMS (HCC) Risk Adjustment guidelines.
• Execute coding quality audits across multiple EMRs, databases, and vendor platforms for both employed and independent clinic risk‑adjustment strategies.
• Identify revenue, reimbursement, and provider educational opportunities while remaining compliant with state and federal regulations.
• Prepare and perform auditing analysis and provide feedback on non‑compliance issues detected through auditing.
• Comply with all aspects of coding, uphold ethical standards, and follow official coding guidelines.
• Conduct provider education and training on risk adjustment through venues such as provider offices, hospitals, webinars, conference calls, and email correspondence.
• Provide measurable, actionable solutions to providers to improve documentation and coding accuracy for chronic condition recapture.
• Ensure rendered physician services for claim submission and subsequent payments are accurate and compliant with CMS, DHS, and OIG guidelines.
• Assist coding leadership by recommending process improvements to enhance coding quality goals and outcomes.

Education & Skills

• High School Diploma required or equivalent.
• Excellent written and verbal communication skills.
• Ability to drive within assigned areas or travel overnight for internal or external meetings.
• Capacity to attend remote provider meetings day/evening/weekends as needed within assigned regions.

Experience

• At least three (3) years of hospital inpatient/outpatient or medical office coding experience, preferably three (3) years of risk adjustment coding experience.
• Prior experience teaching/training others on correct coding guidelines and the ability to present to large groups of physicians/providers.

Licenses, Registrations, or Certifications

• Coding certification required through AHIMA or AAPC (at least two of the below):
• Certified Professional Coder (CPC) – required
• Certified Risk Adjustment Coder (CRC) – preferred
• Certified Coding Specialist for Providers (CCS‑P) – preferred
• Registered Health Information Management Technician (RHIT) – preferred
• Certified Coding Specialist for Providers (CPMA) – preferred
• Certified Coding Specialist for Providers (CDEO) – preferred

Schedule

Full‑time, 5 days per week, 8 hours per day.