Risk Adjustment Auditor Educator

Centene Corporation; Town of Florida (NY); Hybrid; USD 11,000 - 101,000; Full time

Benefits offered by this job

Health insurance

401K

Stock purchase plans

Tuition reimbursement

Paid time off

Flexible work arrangements

Job summary

Centene Corporation is seeking a Senior Risk Adjustment Auditor to support CMS payments and quality of care across our provider network in New York. The role emphasizes education, audits, and data analysis of MRA patterns, with collaboration across Provider Relations and Quality teams.

You will lead training efforts, participate in the RADV Committee, and ensure compliance with risk adjustment guidelines while maintaining policy standards and high accuracy in coding.

Qualifications

• Bachelor's degree or equivalent experience required.
• 5+ years of experience in hospital, physician setting or MCO as a medical coder.
• 2+ years of coding experience with Medicare risk adjustment (HCC Coding).
• Experience in teaching, training or educator/instructor role; provider education preferred.

Responsibilities

• Conduct provider medical record audits and CMS data validation.
• Analyze MRA data to identify patterns and develop interventions at the provider and market level.
• Educate and train providers on risk adjustment to ensure accurate CMS payments and improved quality of care.
• Coordinate with Provider Relations, Quality and Medical Director to ensure CMS risk adjustment guidelines are met.
• Serve on the RADV Committee as subject matter experts.
• Perform QA auditing for ICD-9/ICD-10 coding and communicate results with retraining topics.
• Assist with additional risk adjustment audit requests as needed.
• Comply with all policies and standards.

Skills

Medical coding

Risk adjustment

Education delivery

CMS data validation

Training delivery

Education

Bachelor's degree

CPC or CCS licensure

CRC within 1 year

CPMA preferred

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.

• 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.
• Complies with all policies and standards

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 Other experience in teaching, training or an educator/instructor role required; but provider education experience is preferred

Preferred Other Managed Care Experience:

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

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