Sr. Risk Adjustment Auditor

Your Role

The Risk Adjustment Auditor is a key contributor within the Clinical Documentation Integrity (CDI) program, responsible for ensuring the accuracy, completeness, and compliance of risk adjustment coding and documentation across both internal teams and third-party vendors. This role operates across concurrent and retrospective review workflows, auditing clinical documentation, coded data, and claims to verify adherence to ICD-10-CM guidelines, CMS Medicare risk adjustment requirements, MEAT criteria, and HCC capture standards.

• Audit third-party vendor coding and CDI outputs to ensure accuracy, compliance, and adherence to contracted performance standards
• Audit internal CDI Specialist I and II work, including chart reviews, queries, and reconciliation activities
• Identify coding inaccuracies, unsupported diagnoses, missed HCC opportunities, and documentation gaps
• Deliver audit findings, trend analysis, and corrective action recommendations to CDI leadership and vendor partners
• Track and report audit performance metrics to support continuous quality improvement initiatives
• Review completed encounters in the post-visit, pre-billing window to validate documentation completeness and coding accuracy
• Evaluate alignment between medical record documentation and draft claims, ensuring proper HCC capture
• Assess each diagnosis for appropriate ICD-10-CM specificity and MEAT criteria compliance
• Prioritize high-impact conditions and risk-adjustable diagnoses for intervention and resolution
• Ensure compliant query practices aligned with AHIMA and ACDIS standards
• Review query quality, provider responses, and documentation updates to confirm clinical support for diagnoses
• Validate final alignment between documentation and submitted claims, resolving discrepancies in partnership with coding and billing teams
• Translate audit findings into targeted provider and team education on documentation, coding specificity, and risk adjustment compliance
• Partner with CDI, coding, and leadership teams to improve workflows, policies, and audit readiness
• Serve as a subject matter expert and resource on risk adjustment, CDI best practices, and audit standards
• Support the evolution of CDI and audit processes as automation, EMR integrations, and vendor models mature
• Identify opportunities to expand audit scope (e.g., documentation patterns, provider performance trends, process inefficiencies)
• Contribute to the development of scalable audit frameworks and quality assurance methodologies
• Deliver real-time and aggregate coding and documentation feedback to providers and their clinical support teams
• Design and facilitate education sessions on ICD-10-CM specificity, chronic condition documentation, HCC coding, and risk adjustment compliance both virtually and, on occasion, in person

Qualifications

• Associate’s or Bachelor’s degree in Health Information Management, Nursing, or a related clinical field (or equivalent experience)
• 5+ years of experience in risk adjustment, medical coding, CDI, or auditing
• 2+ years of experience in prospective and concurrent review risk adjustment coding and auditing
• Direct experience with Medicare Advantage (Part C) risk adjustment models and HCC coding required
• Experience auditing vendor-delivered work and/or CDI programs preferred
• One or more of the following certifications:
• CRC (Certified Risk Adjustment Coder) and CPC (Certified Professional Coder) are required
• CCS (Certified Coding Specialist) or CCDS (Certified Clinical Documentation Specialist) is preferred
• RHIT/RHIA is preferred

Pay

The base pay range for this role is $76,600 - $88,899. Compensation takes into account several factors including but not limited to a candidate’s experience, education, skills, licensure and certifications, and organizational needs.