Head of Risk Adjustment QA & Auditing

Excellus BCBS; City of Binghamton (NY); Hybrid; USD 72,000 - 129,000; Full time

Benefits offered by this job

Remote work possible

Job summary

Excellus BCBS in New York is seeking a Supervisor, Risk Adjustment Quality Assurance and Auditing to oversee the QA Auditor team and ensure accuracy, compliance, and quality of risk adjustment coding audits.

The role provides leadership, training, and performance management to audit staff, driving continuous process improvements and efficiency while aligning with CMS, ICD-10-CM guidelines and internal policies.

Qualifications

• Five (5) years ICD-10-CM and Hierarchical Condition Category (HCC) coding experience required and experience in CMS and HHS Risk Adjustment Data Validation Audits (RADV and HRADV).
• Prior experience supervising or managing people and/or projects or indirectly leading teams.
• CPC and CRC certifications required. Other current coding certification (CPC-H, CPC-I, CCS, RHIA, or RHIT) preferred by AAPC or AHIMA.
• Advanced knowledge of medical terminology, abbreviations, anatomy and physiology, major disease processes, and pharmacology. Knowledge of healthcare industry.

Responsibilities

• Provide strategic oversight, supervision, and support to a team of Risk Adjustment Quality Assurance Auditors, ensuring all audit activities strictly adhere to state, federal, and corporate standards.
• Direct and coordinate the day-to-day operations of the Risk Adjustment QA Audit team, ensuring coding accuracy, regulatory compliance, and consistent application of CMS, ICD-10-CM, and organizational guidelines.
• Oversee risk adjustment audit activity including monthly internal coding quality audits and all federal and state risk adjustment data validation audits including, but not limited to, IPM, RADV, and HRADV.
• Documents and defines audit project expectations and parameters for the Risk Adjustment Quality Assurance Auditors in keeping with department, corporate, state, and federal deadlines.
• Assists the Risk Adjustment Coding Educator Manager and Training Lead in identifying areas of opportunity for external business partners and internal coding and audit staff for coding and audit education based on internal quality assurance and state and federal audits.

Skills

ICD-10-CM coding

HCC coding

CMS RADV

HRADV

Leadership

Education

Associate’s degree in a health care related field

CPC certification

CRC certification

CDEO certification

Job description

Excellus BCBS in New York is seeking a Supervisor, Risk Adjustment Quality Assurance and Auditing to oversee the QA Auditor team and ensure accuracy, compliance, and quality of risk adjustment coding audits.

The role provides leadership, training, and performance management to audit staff, driving continuous process improvements and efficiency while aligning with CMS, ICD-10-CM guidelines and internal policies.