Risk Adjustment Compliance Auditor (Remote)

Risk Adjustment Compliance Auditor

Alignment Health is seeking a remote Risk Adjustment Compliance Auditor to support auditing and compliance activities related to risk adjustment data submitted to CMS. This role requires an experienced certified coder with a strong understanding of risk adjustment, HCC coding, compliance auditing, and CMS guidelines.

• Conduct provider and coder-level audits, review medical record documentation and coding accuracy, identify compliance risks and outliers, and support RADV and other risk adjustment audit initiatives.
• Partner closely with Risk Adjustment leadership and cross-functional teams to help ensure coding accuracy, regulatory compliance, audit readiness, and corrective action follow-through across the organization.
• Maintain and develop audit tracking, reporting, and management tools related to Risk Adjustment Compliance activities.
• Ensure compliance with all applicable federal, state & local regulations, as well as institutional/organizational standards, practices, policies & procedures.
• Monitor coding prevalence reporting, internal reporting trends, and coding outliers to support compliance and audit readiness.
• Review IPA Policies and procedures to ensure programs are compliant.
• Maintain internal coding staff accuracy percentages and coding vendor's accuracy percentages.
• Work with Risk Adjustment Management on data validation and RADV coding audit activities, including review of audit outcomes, findings, completeness, and coding accuracy of submissions to CMS.
• Monitor internal coding staff accuracy percentages to ensure they are tracked and maintained.
• Monitor coding vendor’s accuracy percentages to ensure the coding accuracy and quality of the data submitted to CMS.
• Support data validation and RADV coding audit activities, including review of audit outcomes, findings, completeness, and coding accuracy of submissions to CMS.
• Work with Risk Adjustment Management to monitor HCC corrective action plans and follow-up activities related to audit and review findings.
• Suggest customizations of Risk Adjustment education for support staff, PCPs, specialists, employees, contracted employees and central departments.
• Utilize, protect, and disclose Alignment Healthcare patients’ protected health information (PHI) only in accordance with Health Insurance Portability and Accountability Act (HIPAA) standards.
• Maintain current knowledge of CMS audit processes, risk adjustment regulations, and industry best practices through ongoing education, professional development, and participation in relevant professional organizations.
• Contribute to team effort by accomplishing related results as needed.
• Represent and actively participate in RADV and other risk adjustment-related audits and compliance activities.

Job Requirements

• Minimum 3 years of professional coding experience in a medical group or health plan setting.

Education

• Required: Bachelor’s degree in business administration, health care management or in a related field or 4 years additional experience in lieu of education.

Training

• Certified Coder required - CPC, CCS & CCS-P.

Specialized Skills

• Experience with strategic planning in risk mitigation.
• Previous use of Epic, Allscripts, EZCap a plus.
• Proficient user in MS office suite, MS access a plus.
• Ability to communicate positively, professionally and effectively with others; provide leadership, teach and collaborate with others.
• Effective written and oral communication skills; ability to establish and maintain a constructive relationship with diverse members, management, employees and vendors.
• Mathematical Skills: Ability to perform mathematical calculations and calculate simple statistics correctly.
• Reasoning Skills: Ability to prioritize multiple tasks; advanced problem-solving; ability to use advanced reasoning to define problems, collect data, establish facts, draw valid conclusions, and design, implement and manage appropriate resolution.
• Problem-Solving Skills: Effective problem solving, organizational and time management skills and ability to work in a fast-paced environment.
• Report Analysis Skills: Comprehend and analyze statistical reports.

Essential Physical Functions

• Regularly required to talk or hear.
• Frequently lift and/or move up to 10 pounds.

Pay Range

$64,384.00 - $96,577.00

Equal Opportunity/Affirmative Action Employer

All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, disability, age, protected veteran status, gender identity, or sexual orientation.