Execute audit procedures as outlined by Leadership including perform and document findings of quality accuracy reviews/quality audits of coding and documentation completed by Companies Internal Risk Adjustment Coders/Auditors to ensure consistency and accuracy of ICD-10 coding and industry standards.
Advise Companies Internal Coders/Auditors on proper code selection, documentation guidelines as well as assist with training and education.
Research and communicate ICD-10, Coding Clinics, and other industry standard guidance, when appropriate, for facilitating quality review findings and education.
Perform and document findings of quality accuracy reviews/quality audits of coding and documentation completed by External Vendors, Partners and/or Provider Groups to ensure consistency and accuracy of ICD-10 coding.
Communicate with external Vendors, Partners and/or Provider Groups to share out audit results and educational materials.
Escalates trends in quality accuracy reviews/quality audits findings to Leadership and provide suggested corrective actions
Assists Leadership and resources to support audit scope, deadlines, and objectives.
Assist Leadership with improvements to the quality accuracy reviews/quality audits process, identifying risks, evaluating controls, and preparing documentation.
Assists in developing, maintaining, and updating departmental procedures, workflows, and other work tools/job aides.

4+ years related work experience or equivalent combination of transferable experience in Risk Adjustment Coding, Auditing, Coding Accuracy experience and/or Provider Education
Related Bachelor’s degree or additional related equivalent work experience or equivalent work experience
Demonstrated knowledge of CMS and HHS Risk Adjustment Programs Experience resolving escalated issues and barriers.
Excellent communication and collaboration skills both with internal and external audiences
Knowledge of health plan operations
Knowledge of provider operations
CRC (Certified Risk Adjustment Coder from AAPC) Upon Hire
At least one of the following upon hire:
CPC (Certified Professional Code from AAPC)
COC (Certified Outpatient Coder from AAPC)
CIC (Certified Inpatient Coder from AAPC)
CCS (Certified Coding Specialist from AHIMA)
CCS-P (Certified Coding Specialists Physician Based from AHIMA)

Senior Medical Quality Auditor – Risk Adjustment

Key skills