Hybrid Risk Adjustment Coding Auditor | Medicare Advantage

Clever Care Health Plan; Huntington Beach (CA); Hybrid; USD 73,000 - 85,000; Full time

Job summary

Clever Care Health Plan in Huntington Beach, CA is seeking a Risk Adjustment Coding Auditor to conduct retrospective and prospective coding audits, validate diagnoses, and support CMS RADV readiness.

This hybrid role requires 3 days onsite at the Huntington Beach office, with focus on ICD-10-CM, HCC models, and provider documentation improvement to ensure accurate risk scores and compliant reporting. Competence in data analysis and education for providers is essential.

Qualifications

• Bachelor's degree in Health Information Management, Nursing, Healthcare Administration, Public Health, or related discipline; equivalent combination of education and experience may be considered.
• Minimum of five (5) years of experience in Medicare Advantage Risk Adjustment, HCC coding, coding audits, compliance auditing, provider education, or related healthcare auditing functions.
• Minimum of three (3) years of experience conducting risk adjustment coding audits and diagnosis validation reviews.
• Certifications: CPC, CCS, CCS-P, CRC, CPMA, RHIT, or RHIA (one or more)

Responsibilities

• Conduct retrospective, prospective, and targeted coding audits to assess accuracy, completeness, and compliance of ICD-10-CM coding and HCC capture.
• Review medical record documentation to validate reported diagnoses and ensure adherence to CMS risk adjustment data submission requirements.
• Perform diagnosis validation and deletion reviews to identify unsupported or inaccurately coded conditions.
• Lead second-level QA reviews and root cause analysis related to coding accuracy and documentation quality.
• Support CMS RADV audit readiness activities, including chart validation reviews and mock audits.
• Identify trends and risks through analysis of coding, documentation, and vendor performance data.
• Develop and maintain audit methodologies, QA protocols, and compliance monitoring processes.
• Deliver provider education related to risk adjustment coding and CMS requirements.

Skills

CMS Risk Adjustment

HCC coding

Medical record auditing

Provider documentation review

Data analysis

Communication skills

Project management

Regulatory knowledge

Education

Bachelor's degree (Health Information Management / Nursing / Healthcare Administration / Public Health)

Tools

Excel

Word

PowerPoint

Outlook

Job description

Clever Care Health Plan in Huntington Beach, CA is seeking a Risk Adjustment Coding Auditor to conduct retrospective and prospective coding audits, validate diagnoses, and support CMS RADV readiness.

This hybrid role requires 3 days onsite at the Huntington Beach office, with focus on ICD-10-CM, HCC models, and provider documentation improvement to ensure accurate risk scores and compliant reporting. Competence in data analysis and education for providers is essential.