Medicare Risk Adjustment (MRA) Coding Auditor | Certified Risk Adjustment Coder (CRC) | Remote

Alignment Healthcare USA, LLC in; Orange (CA); Remote; USD 64,000 - 97,000; Full time

Job summary

Alignment Health is seeking a remote MRA Coding Auditor to support QA audits of the Coding Analyst team and vendors, ensuring accurate data submitted to CMS.

You will collaborate with Risk Adjustment Management on data validation, chart reviews, and process improvements, maintaining HIPAA compliance and professional standards.

Required certifications and 3+ years in Medicare Risk Adjustment coding, with a high school diploma and coding training; bachelor’s in a related field is preferred.

Qualifications

• Minimum three years of Medicare Risk Adjustment coding in a medical group or health plan setting.
• High School Diploma or GED; completion of a Medical Coding training program.
• Bachelor’s degree in Business Administration, health Care Management or in a related field.
• Technical School or courses that are required to become a certified coder.
• Certified Coder required, CCS, CCS-P, CPC, or CRC.

Responsibilities

• Supports QA audits of internal Coding Analyst Team to validate coding quality (95% HCC accuracy).
• Tracks and reports progress of QA audits on coding vendors for CMS submissions.
• Collaborates with Risk Adjustment Management on MRA data validation and coding audits.
• Analyzes audit results to support training and process improvements.
• Ensures HIPAA compliance and protects PHI in line with standards.
• Maintain CEUs and professional knowledge through workshops and publications.

Skills

Medicare risk adjustment coding

MS Office

Epic

Allscripts

Excel

Communication

Leadership

Education

High School Diploma or GED

Medical Coding training

Bachelor’s degree in Business Administration or Healthcare Management

Tools

EZCap

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.

This is a remote position.

The MRA Coding Auditor supports departmental Quality Assessment audits of internal Coding Analyst team and vendors to ensure accurate and complete data is submitted to CMS. Assists in Risk Adjustment related data audits (RAF, prevalence, clinical documentation improvement, P360, process) audits to identify areas of opportunity for improvement (training, data integrity, chart reviews).

GENERAL DUTIES/RESPONSIBILITIES:

1. Supports regular quality assurance (QA) audits of internal Coding Analyst Team to validate and confirm coding & abstracting quality (95% HCC accuracy). These ongoing audits ensure coding quality & performance improvement standards are maintained, achieved & improved per department policies and procedures.
2. Tracks and reports progress of QA audits performed on the coding vendors to verify the coding accuracy and quality of the data submitted to AHP is accurate for submission to CMS.
3. Works with Risk Adjustment Management on any MRA data validation / coding audit to ensure completeness and coding accuracy of all submissions to CMS. This work may encompass reviews of data for reconciliation, data flow integrity, UAT testing, high cost / low risk score members, retrospective chart reviews, or other risk adjustment related data review as directed by Manager.
4. Analyzes and shares audit results with Manager. This information may be used for training physicians and clinical staff, documentation improvement, and system / process improvement.
5. Utilizes, protects, and discloses Alignment Healthcare patients’ protected health information (PHI) only in accordance with Health Insurance Portability and Accountability Act (HIPAA) standards.
6. Ensures compliance with all applicable federal, state & local regulations, as well as with institutional/organizational standards, practices, policies & procedures.
7. Maintains professional / technical knowledge by attending appropriate educational workshops; reviewing professional publications; establishing personal networks; and participating in professional societies. Stay current of industry coding, compliance, and HCC issues. Required to maintain relevant continuing education units (CEUs) in relation to individual coding certifications.
8. Other duties as assigned to meet the organization’s needs.

Job Requirements:

Experience

• Minimum three years of Medicare Risk Adjustment coding in a medical group or health plan setting required

Education

• High School Diploma or GED. Completion of a Medical Coding training program.
• Bachelor’s degree in Business Administration, health Care Management or in a related field

Training

• Technical School or courses that are required to become a certified coder.

Specialized Skills

• Proficient user in MS office suite – Excel, Word, Outlook Previous use of Epic, Allscripts, EZCap 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

• Certified Coder required, CCS, CCS-P, CPC, or CRC

Work Environment

The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

Essential Physical Functions

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential 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.

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.