Remote Risk Adjustment Auditor & QA Specialist

name; Town of Florida (NY); Remote; USD 83,000 - 109,000; Full time

Benefits offered by this job

Unlimited vacation

Annual performance bonus

Benefits package

Job summary

Oscar Health is looking for an Associate, Risk Adjustment Auditor to join our Risk Adjustment team. The role conducts internal and external quality audits focusing on ICD-10 code abstraction for accuracy and documentation improvement opportunities.

You will report to the Manager, Risk Adjustment, and work remotely from home, with occasional travel for team meetings and events. This position supports CMS/HHS audits and QA initiatives across MA and ACA lines of business.

Qualifications

• Bachelor's degree in a relevant field or commensurate work experience.
• CPC (Certified Professional Coder) certification required.
• 3+ years of retrospective risk adjustment coding experience.
• 1+ year in quality auditing or RADV experience.

Responsibilities

• Responsible for daily operations pertaining to Risk Adjustment including but not limited to: medical record reviews to report ICD-10-CM diagnosis codes for ACA and MA lines of business, potential CMS, HHS audits and medical record retrieval efforts.
• Mitigate risk by validating EDGE data is supported within provider encounter documentation.
• Review the performance of the Risk Adjustment Coding team and report audit trends to Leadership in a timely, consistent and effective manner to ensure the appropriate changes and education are implemented.
• Maintain compliance with ICD-10-CM coding guidelines for accuracy and with risk adjustment production standards.
• Conduct CMS audits of Risk Adjustment activities, including RADV audits.
• Develop relationships with key individuals to foster understanding of the Risk Adjustment process.
• Identify and execute on creating clinical document improvement resources for provider education in MA and ACA lines of business.
• Manage the implementation process improvements to maximize risk adjustment factor increases.
• Compliance with all applicable laws and regulations.
• Other duties as assigned

Skills

CPC Certification

Risk Adjustment Coding

Quality Auditing

CMS/HHS Audits

ICD-10-CM Coding

Education

Bachelor's degree or equivalent experience

Tools

EMR systems

EDGE data

Job description

Oscar Health is looking for an Associate, Risk Adjustment Auditor to join our Risk Adjustment team. The role conducts internal and external quality audits focusing on ICD-10 code abstraction for accuracy and documentation improvement opportunities.

You will report to the Manager, Risk Adjustment, and work remotely from home, with occasional travel for team meetings and events. This position supports CMS/HHS audits and QA initiatives across MA and ACA lines of business.