Primary Job Purpose
The Risk Adjustment Auditor II performs Retrospective/Prospective chart review both on and off-site utilizing various types of records to ensure accurate risk adjustment reporting. Identifies trends in provider coding/documentation and works closely with Provider Education Consultants to develop intervention strategies.
General Functions and Outcomes
- Performs Retrospective and Prospective chart reviews to ensure accurate risk adjustment reporting.
- 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 categories.
- Identifies trends in provider coding and documentation and partners with Provider Education Consultants to develop intervention strategies.
- Supports and actively participates in process and quality improvement initiatives.
- Maintains knowledge of relevant regulatory mandates and ensures activities are in compliance with requirements.
- Consistently meets departmental performance and attendance requirements.
- Serves as a mentor to Risk Adjustment Auditor I staff.
- Assists with special projects such as risk mitigation reviews.
- Serves as subject matter resource regarding the risk adjustment process and diagnosis coding for risk adjustment.
- Monitors and interprets regulatory changes that may impact administration of the Risk Adjustment Program. Assists with implementation activities as a result of regulatory changes to the Program.
Normally to be proficient in the competencies listed above
- Demonstrated ability to perform accurate and complete chart reviews for risk adjustment.
- Knowledge of and adherence to Official ICD-9-CM/ICD-10 Coding Guidelines.
- Demonstrates analytical ability to identify problems, develop solutions, and implement actions in a timely manner.
- Demonstrated ability to identify and communicate trends in provider coding and documentation.
- Demonstrated proficient PC skills and familiarity with corporate software, such as Word, Excel and Outlook.
- Effective verbal and written communication skills.
- 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.
Risk Adjustment Auditor II would have an Associate degree in Healthcare or related field and three years of experience in clinical coding or auditing or equivalent combination of education and experience. Coding Certification (CCA, CCS, CCS-P, CPC, or CPC-P) required. Risk Adjustment, HCC or Inpatient coding experience preferred.
- May be required to work overtime.
- May be required to work outside normal hours.
We are an Equal Opportunity and Affirmative Action employer dedicated to workforce diversity and a drug and tobacco-free workplace. All qualified applicants will receive consideration for employment without regard to race, color, national origin, religion, age, sex, sexual orientation, gender identity, disability, protected veteran status or any other status protected by law. A drug screen and background check are required.
If you need accommodation for any part of the application process because of a medical condition or disability, please email CambiaCareers@cambiahealth.com
This job has expired.