Risk Adjustment Coding Auditor

Minimum Qualifications

• High school diploma, GED, or equivalent practical experience.
• 7+ years of professional experience in risk adjustment, medical coding, auditing, or a related healthcare field.
• 5+ years of Hierarchical Condition Category (HCC) coding experience utilizing inpatient and outpatient coding guidelines.
• 5+ years of experience auditing Risk Adjustment records.
• 1+ year of experience working in a production-based environment.
• Certified Risk Coder (CRC) certification in good standing and an additional coding certification, or ability to obtain certification within six months of hire.
• Experience with Medicare, ACA Commercial, and Medicaid risk adjustment models.
• Experience interpreting and applying coding policies, regulations, and documentation standards.
• Experience providing written and verbal feedback on coding errors and trends.
• Intermediate proficiency with Microsoft Office Suite (Word, Excel, PowerPoint, Outlook) and Microsoft 365 tools, including Teams.
• Ability to manage multiple priorities in a deadline-driven environment.
• Authorization to work in the United States without sponsorship.

Preferred Qualifications

• Bachelor's degree in Health Information Management, Nursing, Healthcare Administration, or a related field.
• HEDIS and STARS experience.
• Provider education and training experience.
• Risk Adjustment Data Validation (RADV) experience.
• Certified Professional Medical Auditor (CPMA) or additional coding credentials.
• Experience serving as a subject matter expert for risk adjustment programs and diagnosis coding.

About the Job

The Risk Adjustment Coding Auditor ensures the accuracy, completeness, and compliance of coded clinical data to support risk adjustment programs and appropriate reimbursement. This role evaluates coding accuracy, identifies documentation and coding gaps, mitigates regulatory and financial risk, and provides expertise on risk adjustment methodologies. The auditor collaborates with internal stakeholders to improve data integrity and support organizational performance.

Responsibilities

• Conduct retrospective and prospective chart reviews to validate risk adjustment coding accuracy and completeness.
• Audit provider-reported diagnosis codes to ensure compliance with coding guidelines, regulatory requirements, and documentation standards.
• Review medical records to identify opportunities for complete and accurate CMS HCC diagnosis code capture.
• Evaluate risk adjustment coding activities for consistency, accuracy, and adherence to established coding standards and best practices.
• Identify coding and documentation deficiencies and provide written and verbal feedback to stakeholders.
• Ensure compliance with HIPAA, privacy, security, and regulatory requirements while handling patient records and audit data.
• Maintain current knowledge of risk adjustment regulations, coding guidelines, and industry standards.
• Support audit production goals and workload priorities while meeting established quality and timeliness metrics.
• Assist with special projects, including risk mitigation reviews and compliance initiatives.
• Serve as a subject matter expert on risk adjustment coding processes, documentation requirements, and diagnosis coding practices.
• Partner with providers and internal teams to improve coding accuracy and documentation quality.
• Track, document, and report audit findings, trends, and opportunities for process improvement.

Apply now