Risk Adjustment Auditor Educator

Centene Management Company LLC; Nevada; Hybrid; USD 56,000 - 101,000; Full time

Benefits offered by this job

Competitive pay

Health insurance

401K plans

Tuition reimbursement

PTO and holidays

Job summary

Centene Management Company LLC seeks a Risk Adjustment Data Validator who will conduct provider medical record audits, analyze coding patterns, and develop education programs to ensure CMS payment accuracy and quality of care. The role includes leading training across offices, webinars, and calls, with involvement in RADV governance.

The candidate should have 5+ years in hospital or managed care coding, with CPC/CCS or CPMA/CRC certifications, and strong communication skills to coordinate with

Qualifications

• Experience in risk adjustment coding and CMS requirements.
• Ability to educate providers on Dx codes and documentation.
• Strong analytical skills for MRA data patterns and interventions.
• Teaching/training or educator role experience.

Responsibilities

• Audit medical records for ICD-9/ICD-10 coding accuracy and appropriateness.
• Lead provider education and risk adjustment training across venues (offices, webinars, calls).
• Analyze MRA data to identify patterns and develop education plans.
• Serve on the RADV Committee as subject matter experts.
• Communicate QA results and suggest retraining topics.

Skills

Managed Care experience

HCC methodology

Effective communication

Organizational skills

Education

Bachelor’s degree or equivalent experience

CPC or CCS

CPMA within 1 year

CRC within 2nd year

Job description

Position Purpose

Conduct provider medical record audits, analysis of practice coding patterns, education and training regarding risk adjustment to ensure accurate CMS payment and improve quality of care. Analysis of MRA data to identify patterns and development of interventions at the provider and market level.

Key Details

Remote role with Southern Nevada Territory. Subject matter experts for proper risk adjustment coding and CMS data validation. Work in conjunction with other departments to include Provider Relations, Quality as well as the Medical Director for the state assigned to ensure compliance of CMS risk adjustments guidelines are met. Analyze MRA data to identify patterns and development of interventions at the provider and market level to coordinate an educational work plan for WellCare contracted providers. Conduct provider education and training regarding risk adjustment to help to ensure accurate CMS payment and to improve quality of care. This includes training venues such as provider offices, hospitals, webinars, conference calls, email correspondence, etc. Works on additional risk adjustment audit requests (i.e. outside auditors requests). Serves on the RADV Committee as subject matter experts. Perform quality assurance auditing (i.e. ensure appropriateness and accuracy of ICD-9/ICD-10 coding) for WellCare’s Medical Coding Specialists. Communicates QA results to the Medical Coding Specialists with suggestions for improvement and re-training topics. Perform other duties as necessary.

Additional Responsibilities

Performs other duties as assigned. Complies with all policies and standards.

Preferred Skills

Managed Care experience. Strong understanding of HCC methodology, risk-adjustable diagnoses, CMS requirements, and compliant diagnosis capture. Accurately evaluates diagnosis coding and determines whether documentation supports the reported code. Experience working with and educating providers around Dx codes. Clear communication, strong organizational skills, flexibility.

Education / Experience

Bachelor’s degree or equivalent experience required. Candidate Experience: 5+ years of experience in a hospital, a physician setting or a Managed Care Organization as a medical coder. 2+ years of experience in coding with knowledge of Medicare risk adjustment (HCC Coding). Required experience: Teaching, Training or an Educator/Instructor role required; but provider education experience is preferred. Preferred: managed care experience.

Licenses and Certifications

A license in one of the following is required: Required: One of the following certifications are required at the time of hire: CPC or CCS Required: CPMA is required within the first year of employment Required: CRC required on the second year of employment

Pay Range

$56,200.00 - $101,000.00 per year

Benefits

• competitive pay, health insurance, 401K and stock purchase plans, tuition reimbursement, paid time off plus holidays, and a flexible approach to work with remote, hybrid, field or office work schedules.

Equal Opportunity Employer

Centene is an equal opportunity employer that is committed to diversity, and values the ways in which we are different. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, veteran status, or other characteristic protected by applicable law.

Qualified applicants with arrest or conviction records will be considered in accordance with the LA County Ordinance and the California Fair Chance Act.

Company Statement

At Centene, we connect people to the care they need to live healthier lives - and the work you do here makes that impact real every day. You'll take on meaningful challenges that directly support individuals, families, and communities, building your skills while making healthcare more accessible and effective. It's work with a purpose you can see, backed by a team committed to improving lives well beyond the workday. We provide access to high-quality healthcare, innovative programs and a wide range of health solutions that help families and individuals get well, stay well and be well.