Medicare Risk Adjustment Compliance Auditor (CPC, CCS, or CCS-P Required) (Remote)

E2E Alignment Healthcare USA, LLC; California (MO); Remote; USD 64,000 - 97,000; Full time

Job summary

Alignment Health is seeking a Remote Risk Adjustment Compliance Auditor to conduct provider and coder level reviews and audits, ensuring CMS risk adjustment data accuracy. The role develops tracking tools, monitors audit outcomes, and supports corrective action plans across risk adjustment programs.

Required: Bachelor’s degree in business administration or healthcare management or 3+ years coding in a medical group/health plan, plus CPC/CCS/CCS-P certification.

Qualifications

• Bachelor’s degree in business administration, health care management or related field, or 4 years additional experience in lieu of education.
• Certified Coder required - CPC, CCS & CCS-P.
• Minimum 3 years of professional coding experience in a medical group or health plan setting.

Responsibilities

• Monitors coding prevalence reporting for coding outliers.
• Reviews IPA Policies and procedures to ensure programs are compliant.
• Monitors internal coding staff accuracy percentages to ensure they are tracked and maintained.
• Monitors coding vendor’s accuracy percentages to ensure the coding accuracy and quality of the data submitted to CMS.
• Works with Risk Adjustment Management on any data validation and/or RADV coding audit to ensure completeness and accuracy of submissions to CMS.
• Maintains a comprehensive tracking and management tool for Risk Adjustment Compliance.
• Ensures compliance with all applicable federal, state & local regulations and organizational standards.
• Represents the department in RADV and other risk adjustment related audits.

Skills

Risk adjustment

Certified coder (CPC/CCS/CCS-P)

Auditing

Regulatory compliance

Data analysis

Education

Bachelor’s degree in business administration / healthcare management

Tools

Epic

Allscripts

EZCap

MS Office

MS Access

Job description

Alignment Health is breaking the mold in conventional health care, committed to serving seniors and those who need it most: the chronically ill and frail. It takes an entire team of passionate and caring people, united in our mission to put the senior first. We have built a team of talented and experienced people who are passionate about transforming the lives of the seniors we serve. In this fast-growing company, you will find ample room for growth and innovation alongside the Alignment Health community. Working at Alignment Health provides an opportunity to do work that really matters, not only changing lives but saving them. Together.

The Remote Risk Adjustment Compliance Auditor is to conduct provider and coder level reviews and audits to ensure accurate risk adjustment data is being submitted to the CMS. Develops and maintains tracking tools, reviews and audits outcomes / findings and monitors any corrective active plans implemented due to review or audit findings. Monitors internal reporting for outliers, stays up to date with CMS audit processes and actively participates in all audits as they relate to risk adjustment.

Job Duties/Responsibilities

1. Monitors coding prevalence reporting for coding outliers.
2. Reviews IPA Policies and procedures to ensure programs are compliant.
3. Monitors internal coding staff accuracy percentages to ensure they are tracked and maintained.
4. Monitors coding vendor’s accuracy percentages to ensure the coding accuracy and quality of the data submitted to CMS.
5. Works with Risk Adjustment Management on any data validation and /or RADV coding audit(s) to ensure completeness and coding accuracy of all submissions to CMS.
6. Maintains a comprehensive tracking and management tool for Risk Adjustment Compliance.
7. Ensures compliance with all applicable federal, state & and local regulations, as well as institutional/organizational standards, practices, policies & procedures.
8. Works with Risk Adjustment Management to monitor HCC Corrective Action Plans as needed.
9. Suggests customizations of Risk Adjustment education for support staff, PCPs, specialists, employees, contracted employees and central departments.
10. Utilizes, protects, and discloses Alignment Healthcare patients’ protected health information (PHI) only in accordance with Health Insurance Portability and Accountability Act (HIPAA) standards.
11. Maintains professional and technical knowledge by attending educational workshops, reviewing professional publications, establishing personal networks and participating in professional societies.
12. Contributes to team effort by accomplishing related results as needed.
13. Represents the department in RADV and other risk adjustment related audits.
14. Other duties as assigned to meet the organization’s needs.

Job Requirements

Experience:

• Required: Minimum 3 years of professional coding experience in a medical group or health plan setting.
• Preferred: None.

Education:

• Required: Bachelor’s degree in business administration, health care management or in a related field or 4 years additional experience in lieu of education.
• Preferred: None.

Training:

• Required: Certified Coder required - CPC, CCS & CCS-P.
• Preferred: Certified Auditor.

Specialized Skills:

Required: Experience with strategic planning in risk mitigation. Previous use of Epic, Allscripts, EZCap a plus. Proficient user in MS office suite, MS access a plus. Ability to communicate positively, professionally and effectively with others; provide leadership, teach and collaborate with others. Effective written and oral communication skills; ability to establish and maintain a constructive relationship with diverse members, management, employees and vendors; Mathematical Skills: Ability to perform mathematical calculations and calculate simple statistics correctly Reasoning Skills: Ability to prioritize multiple tasks; advanced problem-solving; ability to use advanced reasoning to define problems, collect data, establish facts, draw valid conclusions, and design, implement and manage appropriate resolution. Problem-Solving Skills: Effective problem solving, organizational and time management skills and ability to work in a fast-paced environment. Report Analysis Skills: Comprehend and analyze statistical reports.

Licensure:

• Required: Certified Coder required - CPC, CCS & CCS-P.
• Preferred: None.

Essential Physical Functions:

1. While performing the duties of this job, the employee is regularly required to talk or hear. The employee regularly is required to stand, walk, sit, use hand to finger, handle or feel objects, tools, or controls; and reach with hands and arms.
2. The employee frequently lifts and/or moves up to 10 pounds. Specific vision abilities required by this job include close vision and the ability to adjust focus.

Pay Range: $64,384.00 - $96,577.00 Pay range may be based on a number of factors including market location, education, responsibilities, experience, etc.

Alignment Health is an Equal Opportunity/Affirmative Action Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, disability, age, protected veteran status, gender identity, or sexual orientation.

Alignment Health is championing a new path in senior care that empowers members to age well and live their most vibrant lives. Our mission-focused team makes high-quality, low-cost care a reality for members every day. Alignment Health is breaking the mold in conventional health care, committed to serving seniors and those who need it most. We believe that great work comes from people who are inspired to be their best. We've built a team of people who want to make a difference in the lives of the seniors we serve. Come join the team that is changing health care — one person at a time.