Risk Adjustment Auditor Educator

Centene Corp.; Northern (KY); Hybrid; USD 56,000 - 101,000; Full time

Benefits offered by this job

Health insurance

401K plan

Stock purchase plan

Tuition reimbursement

Paid time off and holidays

Job summary

Centene Corp. is seeking a seasoned Risk Adjustment Auditor to audit provider medical records, analyze CMS risk adjustment patterns, and educate providers to improve CMS payments and care quality.

The role involves collaborating with Provider Relations, Quality, and Medical Directors to ensure CMS guidelines are met and coordinating training across WellCare contracted providers. Relevant licensure and managed care experience are required.

Qualifications

• Bachelor’s degree or equivalent experience required.
• 5+ years in hospital/physician/Managed Care as a medical coder.
• 2+ years in coding with Medicare risk adjustment (HCC Coding).
• Experience in teaching/training or educator role; provider education preferred.
• Other managed care experience preferred.

Responsibilities

• Conduct provider medical record audits and risk adjustment education to ensure CMS payment accuracy.
• Analyze MRA data to identify patterns and develop provider-level interventions.
• Serve as subject matter expert for risk adjustment coding and CMS data validation.
• Coordinate education with Provider Relations, Quality, and Medical Directors to ensure CMS risk adjustments guidelines are met.
• Organize training venues (offices, hospitals, webinars, calls, email) and respond to external audit requests.
• Serve on the RADV Committee as subject matter experts.
• Perform QA auditing of ICD-9/ICD-10 coding and report results with improvement suggestions.

Skills

Medical coding

Risk adjustment

Education/training

CMS data validation

Communication

Education

Bachelor’s degree or equivalent experience

CPC or CCS licensure

CRC within 1st year

CPMA preferred in 2nd year

Job description

You could be the one who changes everything for our 28 million members. Centene is transforming the health of our communities, one person at a time. As a diversified, national organization, you’ll have access to competitive benefits including a fresh perspective on workplace flexibility.

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.
• Act as 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.
• Coordinate an educational work plan for WellCare contracted providers following analysis of MRA data to identify patterns and development of interventions at the provider and market level.
• Conduct provider education and training regarding risk adjustment to help ensure accurate CMS payment and to improve quality of care.
• Organize training venues such as provider offices, hospitals, webinars, conference calls, email correspondence, etc.
• Work on additional risk adjustment audit requests (i.e. outside auditors’ requests).
• Serve 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.
• Communicate QA results to the Medical Coding Specialists with suggestions for improvement and re-training topics.
• Perform other duties as necessary.
• Comply with all policies and standards.

Education / Experience

• Bachelor’s degree or equivalent experience required.
• 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.
• Other experience in teaching, training or an educator/instructor role required; but provider education experience is preferred.
• Other managed care experience preferred.

Licenses and Certifications

• A license in one of the following is required.
• One of the following licensures required at hire: CPC or CCS.
• CRC required within the 1st year of employment.
• CPMA preferred on the 2nd 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.

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.

Centene is committed to helping people live healthier lives. 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.