Risk Adjustment Auditor Educator

SilverSummit Healthplan; Nevada; Hybrid; USD 56,000 - 101,000; Full time

Job summary

Centene is seeking a senior risk adjustment specialist to lead provider education and CMS data validation across assigned markets. You will analyze MRA data, identify patterns, and coordinate with multiple internal teams to ensure accurate coding and compliant CMS risk adjustments.

The role requires 5+ years in hospital/physician/MCO coding, CPC/CCS with CPMA and CRC certifications, and strong communication and organizational skills.

Qualifications

• Bachelor’s degree or equivalent experience required.
• 5+ years in hospital, physician setting or Managed Care Organization as a medical coder.
• 2+ years coding experience with Medicare risk adjustment (HCC Coding).
• Teaching/training/educator role required; provider education preferred.
• Licenses/certifications: CPC or CCS required; CPMA within first year; CRC by second year.

Responsibilities

• Conduct provider education and training on risk adjustment to ensure accurate CMS payments and improve care quality.
• Analyze MRA data to identify patterns and develop provider/market interventions.
• Serve as subject matter expert for risk adjustment coding and CMS data validation.
• Coordinate with Provider Relations, Quality and Medical Director to ensure CMS risk adjustment compliance.
• QA auditing of ICD-9/ICD-10 coding and communicate results with retraining suggestions.
• Fulfill additional risk adjustment audit requests and other duties as assigned.

Skills

Managed Care experience

HCC methodology knowledge

Provider education/training

Clear communication

Organizational skills

Education

Bachelor's degree or equivalent experience

Job description

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

• 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 and 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

• 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

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.

Centene offers a comprehensive benefits package including: 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. Actual pay will be adjusted based on an individual’s skills, experience, education, and other job-related factors permitted by law, including full-time or part-time status. Total compensation may also include additional forms of incentives. Benefits may be subject to program eligibility.

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