Risk Adjustment Auditor

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

Hi, we're Oscar. We're hiring a Associate, Risk Adjustment Auditor to join our Risk Adjustment team.

Oscar is the first health insurance company built around a full stack technology platform and a relentless focus on serving our members. We started Oscar in 2012 to create the kind of health insurance company we would want for ourselves - one that behaves like a doctor in the family.

About the role:

The Associate, Risk Adjustment Auditor conducts internal and external quality audits. Quality audits are specific to ICD-10 code abstraction relative to accuracy, completeness, and identified clinical documentation improvement opportunities. You will work with management to implement benchmarks, establish acceptable thresholds, and quality assurance programs.

You will report into the Manager, Risk Adjustment.

Work Location:

This is a remote position, open to candidates who reside in: Arizona; Florida; Georgia; or Texas. While your daily work will be completed from your home office, occasional travel may be required for team meetings and company events. #LI-Remote

Pay Transparency:

The base pay for this role is: $82,717 - $108,566 per year You are also eligible for employee benefits, participation in Oscar's unlimited vacation program and annual performance bonuses.

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 Centers of Medicare & Medicaid Services (CMS), Health and Human Services (HHS) audits and medical record retrieval efforts.
• Mitigate risk by validating Encounter Data Gathering Environment Server (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 national standards and coding practices set by the ICD-10-CM coding guidelines for accuracy, as well as compliance with Risk adjustment production standards.
• Conduct CMS audits of Risk Adjustment activities, including but not limited to Risk Adjustment Data Validation audits.
• Develop relationships with key individuals to foster an increased understanding of the Risk Adjustment process.
• Identify and execute on the creation of clinical document improvement resources for provider education in both MA and ACA line of business.
• Manage the implementation process improvements that will maximize risk adjustment factor increases.
• Compliance with all applicable laws and regulations
• Other duties as assigned

Requirements:

• Bachelor's degree in a relevant field of study or commensurate work experience.
• Certified professional coder (CPC)
• 3+ year(s) retrospective risk adjustment coding experience.
• 1+ year(s) experience Quality Auditing and/or Risk Adjustment Data Validation Audit (RADV) experience

Bonus points:

• Certified Risk Adjustment Coder (CRC) or similar certification
• Experience coding in a variety of different Electronic Medical Record (EMR) systems.

This is an authentic Oscar Health job opportunity.

At Oscar, being an Equal Opportunity Employer means more than upholding discrimination-free hiring practices. It means that we cultivate an environment where people can be their most authentic selves and find both belonging and support. We're on a mission to change health care - an experience made whole by our unique backgrounds and perspectives.

Pay Transparency:

Final offer amounts, within the base pay set forth above, are determined by factors including your relevant skills, education, and experience. Full-time employees are eligible for benefits including: medical, dental, and vision benefits, 11 paid holidays, paid sick time, paid parental leave, 401(k) plan participation, life and disability insurance, and paid wellness time and reimbursements.

Artificial Intelligence (AI):

Our AI Guidelines outline the acceptable use of artificial intelligence for candidates and detail how we use AI to support our recruiting efforts.

Reasonable Accommodation:

Oscar applicants are considered solely based on their qualifications, without regard to applicant’s disability or need for accommodation. Any Oscar applicant who requires reasonable accommodations during the application process should contact the Oscar Benefits Team ([e-mail]) to make the need for an accommodation known.

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