Quality Assurance Risk Adjustment Auditor I/II

About the role

Risk Adjustment Auditor I or II Hybrid role (3 days/week in office). Candidates must reside within commutable distance of that location. Build a career with purpose. Join our Cause to create a person-focused and economically sustainable health care system.

Responsibilities

• Builds accurate risk adjustment reports through retrospective and prospective chart reviews.
• Aids in second-level reviews of new HCCs identified during the first pass chart review process.
• Identifies trends in provider coding/documentation and vendor risk adjustment reporting and communicates these trends to leadership and relevant teams.
• Supports process and quality improvement initiatives.
• Maintains knowledge of relevant regulatory mandates and ensures compliance.
• Maintains departmental performance and attendance requirements.

Qualifications

• Risk Adjustment Auditor I: Associate degree in Healthcare or related field and one year of experience in clinical coding or auditing or equivalent combination of education and experience. Risk Adjustment, HCC or Inpatient coding experience required. CPC and CRC coding certification required.
• Risk Adjustment Auditor II: Associate degree in Healthcare or related field and three years of experience in clinical coding or auditing or equivalent combination of education and experience. Risk Adjustment, HCC or Inpatient coding experience required. CPC and CRC coding certification required.

Skills and Attributes

• Demonstrated ability to perform accurate and complete chart reviews for risk adjustment.
• Demonstrated ability to perform quality audits of internal and vendor coding.
• Knowledge of and adherence to Official ICD-9-CM/ICD-10 Coding Guidelines.
• Demonstrated analytical ability to identify problems, develop solutions, and implement actions in a timely manner.
• Demonstrated ability to identify and communicate trends in provider and vendor coding and documentation.
• Demonstrated proficient PC skills and familiarity with corporate software, such as Word, Excel and Outlook.
• Effective verbal and written communication skills.
• Experience with AI tools and technologies to enhance productivity and decision-making in professional settings highly desired.

Additional Skills and Attributes

• Risk Adjustment Auditor II: Knowledge of health systems operations, including an understanding of reimbursement methodologies and coding conventions for governmental and commercial products.
• Advanced knowledge and understanding of risk adjustment, coding and documentation requirements.
• Demonstrated ability to provide proactive and creative solutions to business problems.

What You Will Do

• Performs Retrospective and Prospective chart reviews to ensure accurate risk adjustment reporting.
• Performs quality reviews of vendor coding in support of the risk adjustment process.
• Verifies and ensures the accuracy, completeness, specificity and appropriateness of provider-reported diagnosis codes based on medical record documentation.
• Reviews medical record information to identify complete and accurate diagnosis code capture based on CMS HCC and HHS HCC categories.
• Identifies trends in provider and vendor coding and documentation and partners with coding team manager and training lead to develop intervention strategies.
• Supports and actively participates in process and quality improvement initiatives.

Work Environment

• Work primarily performed in office or remote environment.
• Travel may be required, locally or out of state.
• May be required to work overtime.
• May be required to work outside normal hours.

Pay and Benefits

• Risk Adjustment Auditor I: Expected hiring range is $57,800.00 – $78,200.00, full salary range is $54,000.00 – $89,000.00, bonus target is 5%.
• Risk Adjustment Auditor II: Expected hiring range is $69,700.00 – $94,300.00, full salary range is $65,000.00 – $107,000.00, bonus target is 10%.

About Cambia

Working at Cambia means being part of a purpose-driven, award-winning culture built on trust and innovation anchored in our 100+ year history. Our caring and supportive colleagues are some of the best and brightest in the industry, innovating together toward sustainable, person-focused health care. Whether we're helping members, lending a hand to a colleague or volunteering in our communities, our compassion, empathy and team spirit always shine through.

Why Join the Cambia Team?

• Work alongside diverse teams building cutting-edge solutions to transform health care.
• Earn a competitive salary and enjoy generous benefits while doing work that changes lives.
• Grow your career with a company committed to helping you succeed.
• Give back to your community by participating in Cambia-supported outreach programs.
• Connect with colleagues who share similar interests and backgrounds through our employee resource groups.

Learn More About Our Benefits

For more information about our benefits, visit our Benefits Page.