Risk Adjustment Auditor: HCC Compliance & Coding

CommunityCare HMO Inc.; Tulsa (OK); On-site; USD 55,000 - 75,000; Full time

Job summary

CommunityCare HMO Inc. seeks a Risk Adjustment Auditor to review medical records and documentation, ensuring accurate capture of diagnoses per CMS risk adjustment guidelines and ICD-10-CM standards. This role supports accurate risk scores, regulatory compliance, and program integrity.

The auditor will perform both retrospective and prospective reviews, identify coding gaps, and collaborate with coding teams to improve documentation quality. HIPAA compliance is essential.

Qualifications

• A minimum of two years of risk adjustment coding or auditing experience.
• Experience reviewing medical records across multiple specialties.
• Certified Professional Coder (CPC), CRC, CCS, or equivalent coding certification.
• Bachelor’s degree in Health Information Management or related field preferred.

Responsibilities

• Perform bi-directional retrospective and prospective medical record reviews to validate diagnoses.
• Ensure documentation supports coded conditions per ICD-10-CM and CMS guidelines.
• Identify unsupported diagnoses, over- or under-coding, and gaps in documentation.
• Provide audit findings and recommendations to coding teams, providers, and leadership.
• Monitor RADV standards and report audit results and trends.
• Collaborate with coding staff, providers, and operations to improve accuracy.
• Assist with education and training on risk adjustment and documentation best practices.
• Maintain confidentiality and ensure HIPAA compliance.
• Meet daily and weekly productivity and quality standards.

Skills

CMS-HCC knowledge

ICD-10-CM guidelines

RADV requirements

EMR proficiency

Microsoft Office

Attention to detail

Analytical thinking

Communication skills

Independent work

Time management

Education

CPC

CRC

CCS

Bachelor's degree in Health Information Management or related field

Tools

EMR systems

Microsoft Office

Job description

CommunityCare HMO Inc. seeks a Risk Adjustment Auditor to review medical records and documentation, ensuring accurate capture of diagnoses per CMS risk adjustment guidelines and ICD-10-CM standards. This role supports accurate risk scores, regulatory compliance, and program integrity.

The auditor will perform both retrospective and prospective reviews, identify coding gaps, and collaborate with coding teams to improve documentation quality. HIPAA compliance is essential.