QA Risk ADj Auditor II

Cambia Health Solutions; Idaho; Hybrid; USD 58,000 - 89,000; Full time

Benefits offered by this job

Work from home options

Office flexibility

Job summary

Cambia Health Solutions is seeking a Risk Adjustment Auditor I or II for a hybrid role with three days in office across designated U.S. locations, including OR/UT/ID states.

The role focuses on retrospective and prospective chart reviews to ensure accurate risk adjustment reporting and coding integrity. You will analyze provider documentation, identify coding trends, and collaborate with the coding team and leadership to implement corrective actions.

Qualifications

• Associate degree in Healthcare or related field required or equivalent experience.
• Experience with Risk Adjustment, HCC or inpatient coding.
• Certification in CPC and CRC preferred or required.

Responsibilities

• Perform retrospective and prospective chart reviews to ensure accurate risk adjustment reporting.
• Verify accuracy and completeness of provider diagnosis codes based on medical records.
• Identify trends in provider and vendor coding and communicate findings to leadership.

Skills

Risk Adjustment

Auditing

Medical coding

Retrospective chart review

Prospective chart review

Analytical skills

Communication skills

MS Office

AI tools familiarity

Education

Associate degree in Healthcare or related field

Tools

Excel

Word

Outlook

Job description

Risk Adjustment Auditor I or II Hybrid role (3 days/week in office) at our Salt Lake City, Boise, Fargo, Portland, Vancouver, Renton, Medford, Burlington, Lewiston offices.

Preference will be given to current employees and candidates who reside within a commutable distance from our Salt Lake City, Boise, Fargo and Lewiston offices or who are willing to relocate. Build a career with purpose. Join our Cause to create a person-focused and economically sustainable health care system.

Who We Are Looking For

Every day, Cambia’s dedicated team of Risk Adjustment Auditors is living our mission to make health care easier and lives better. As a member of the Risk Adjustment team, the Risk Adjustment Auditor performs Retrospective/Prospective chart review utilizing various types of records to ensure accurate risk adjustment reporting. Responsibilities include assisting in second level reviews of all new HCCs identified through the first pass chart review process. Identifies trends in provider coding/documentation and vendor risk adjustment reporting and makes those trends known to leadership as well as the coding team manager and training lead to develop intervention strategies – all in service of creating a person-focused health care experience.

Do you thrive as part of a collaborative, caring team? Then this role may be the perfect fit.

What You Bring to Cambia

Qualifications:

• Risk Adjustment Auditor I would have an Associate degree in Healthcare or related field and one year of experience in clinical coding or auditing or equivalent combination of education and experience. Risk Adjustment, HCC or Inpatient coding experience required.


• Risk Adjustment Auditor II would have an Associate degree in Healthcare or related field and three years of experience in clinical coding or auditing or equivalent combination of education and experience. Risk Adjustment, HCC or Inpatient coding experience required.

Required Licenses, Certifications, Registration, Etc.:

• CPC and CRC coding certification required

Skills and Attributes:

• Demonstrated ability to perform accurate and complete chart reviews for risk adjustment.


• Demonstrated ability to perform quality audits of internal and vendor coding.


• Knowledge of and adherence to Official ICD-9-CM/ICD-10 Coding Guidelines.


• Demonstrated analytical ability to identify problems, develop solutions, and implement actions in a timely manner.


• Demonstrated ability to identify and communicate trends in provider and vendor coding and documentation.


• Demonstrated proficient PC skills and familiarity with corporate software, such as Word, Excel and Outlook.


• Effective verbal and written communication skills.


• Experience with AI tools and technologies to enhance productivity and decision-making in professional settings highly desired

Additional Skills and Attributes for Risk Adj Auditor II:

• Knowledge of health systems operations, including an understanding of reimbursement methodologies and coding conventions for governmental and commercial products.


• Advanced knowledge and understanding of risk adjustment, coding and documentation requirements.


• Demonstrated ability to provide proactive and creative solutions to business problems.

What You Will Do at Cambia

• Performs Retrospective and Prospective chart reviews to ensure accurate risk adjustment reporting.


• Performs quality reviews of vendor coding in support of the risk adjustment process.


• Verifies and ensures the accuracy, completeness, specificity and appropriateness of provider-reported diagnosis codes based on medical record documentation.


• Reviews medical record information to identify complete and accurate diagnosis code capture based on CMS HCC and HHS HCC categories.


• Identifies trends in provider and vendor coding and documentation and partners with coding team manager and training lead to develop intervention strategies.


• Supports and actively participates in process and quality improvement initiatives.


• Maintains knowledge of relevant regulatory mandates and ensures activities are in compliance with requirements.


• Consistently meets departmental performance and attendance requirements.

Additional Duties for Risk Adj Auditor II

• Serves as a mentor to Risk Adjustment Auditor I staff.


• Assists with special projects such as risk mitigation reviews.


• Serves as subject matter resource regarding the risk adjustment process and diagnosis coding for risk adjustment.


• Monitors and interprets regulatory changes that may impact administration of the Risk Adjustment Program. Assists with implementation activities as a result of regulatory changes to the Program.

Work Environment

• Work primarily performed in office or remote environment.


• Travel may be required, locally or out of state.


• May be required to work overtime.


• May be required to work outside normal hours.

Risk Adjustment Auditor I – Oregon, Utah, and Idaho

The expected hiring range is $57,800.00 – $78,200.00, the full salary range is 54,000.00 – $89,000.00 and the bonus target is 5%.

North Dakota: The full hourly range is $26.03 - $41.65 per hour.

Risk Adjustment Auditor II – Oregon, Utah, and Idaho

The expected hiring range is $69,700.00 – $94,300.00, the full salary range is $65,000.00 – $107,000.00 and the bonus target is 10%.

North Dakota: The full hourly range is $28.70 - $45.93 per hour.

About Cambia

Working at Cambia means being part of a purpose-driven, award-winning culture built on trust and innovation anchored in our 100+ year history. Our caring and supportive colleagues are some of the best and brightest in the industry, innovating together toward sustainable, person-focused health care. Whether we're helping members, lending a hand to a colleague or volunteering in our communities, our compassion, empathy and team spirit always shine through.

Why Join the Cambia Team

• Work alongside diverse teams building cutting-edge solutions to transform health care.


• Earn a competitive salary and enjoy generous benefits while doing work that changes lives.


• Grow your career with a company committed to helping you succeed.


• Give back to your community by participating in Cambia-supported outreach programs.


• Connect with colleagues who share similar interests and backgrounds through our employee resource groups.


• We believe a career at Cambia is more than just a paycheck – and your compensation should be too. Our compensation package includes competitive base pay as well as a market-leading 401(k) with a significant company match, bonus opportunities and more.


• In exchange for helping members live healthy lives, we offer benefits that empower you to do the same. Just a few highlights include: Medical, dental and vision coverage for employees and their eligible family members, including mental health benefits. Annual employer contribution to a health savings account. Generous paid time off varying by role and tenure in addition to 10 company-paid holidays. Market-leading retirement plan including a company match on employee 401(k) contributions, with a potential discretionary contribution based on company performance (no vesting period). Up to 12 weeks of paid parental time off (eligibility requires 12 months of continuous service with Cambia immediately preceding leave). Award-winning wellness programs that reward you for participation. Employee Assistance Fund for those in need. Commute and parking benefits.

We are happy to offer work from home options for most of our roles. To take advantage of this flexible option, we require employees to have a wired internet connection that is not satellite or cellular and internet service with a minimum upload speed of 5Mb and a minimum download speed of 10 Mb. As part of our security requirements, new hires will need access to a personal mobile device to set up Multi-Factor Authentication (MFA) upon joining the company. MFA is an important layer of protection for accessing Cambia systems and is required for all employees.

We are an Equal Opportunity employer dedicated to a drug and tobacco-free workplace. All qualified applicants will receive consideration for employment without regard to race, color, national origin, religion, age, sex, sexual orientation, gender identity, disability, protected veteran status or any other status protected by law. A background check is required. If you need accommodation for any part of the application process because of a medical condition or disability, please email [e-mail].

Information about how Cambia Health Solutions collects, uses, and discloses information is available in our Privacy Policy.

Everyone is a health care consumer deserving of a simpler, more personalized experience. Cambia is transforming the health care system to revolve around people. For over 100 years we’ve designed people-first health solutions rooted in the nation’s first health plan, a loggers’ wage pool established in the Pacific Northwest. Today that pioneering spirit aligns our family of over 20 companies, including 4 not-for-profit BlueCross and BlueShield licensed health plans serving over 3 million Americans. Cambia blends data science with a compassionate human perspective to anticipate people’s needs, and empower them to make smarter health care choices.