Medicare Risk-Adjustment Coding Auditor

sanford; United States; On-site; USD 45,000 - 72,000; Full time

Job summary

Sanford Health is seeking a Coding Audit Specialist to perform quality assurance on CMS and DHS risk adjustment data. You will audit medical records, ensure accurate diagnostic coding, and develop monitoring programs for Medicare Advantage, ACA/Exchange, and BadgerCare Plus populations.

The role requires knowledge of CPT, ICD-9/10, HCC coding and strong documentation review skills; certification within one year is expected.

Qualifications

• High school diploma or equivalent required; proficiency in anatomy/physiology and medical terminology.
• Associate degree in coding or health-related field preferred.
• Three years in health insurance, compliance, quality assurance or auditing; ICD-9/10, CPT, HCC coding knowledge.
• Familiarity with CMS guidelines affecting Medicare Advantage, HHS-ACA and DHS/BadgerCare Plus.
• Certified Professional Coder and/or Certified Risk Adjustment Coder within one year of hire.

Responsibilities

• Audit medical record documentation to ensure correct codes are used.
• Develop and monitor risk adjustment score auditing programs for Medicare Advantage, ACA/Exchange and BadgerCare Plus.
• Identify un-coded or mis-coded diagnoses; provide outcomes and tools for accuracy improvements.
• Ensure documentation supports reported codes per CPT, ICD-9/10 guidelines and CMS policy.
• Present audit findings in a concise, logical summary.

Skills

Anatomy/physiology knowledge

Medical terminology

Auditing

Documentation accuracy

Education

High school diploma or equivalent

Associate degree in coding or health-related field

Tools

Word

Excel

Access

Job description

Sanford Health is seeking a Coding Audit Specialist to perform quality assurance on CMS and DHS risk adjustment data. You will audit medical records, ensure accurate diagnostic coding, and develop monitoring programs for Medicare Advantage, ACA/Exchange, and BadgerCare Plus populations.

The role requires knowledge of CPT, ICD-9/10, HCC coding and strong documentation review skills; certification within one year is expected.