Risk Adjustment Auditor: Precision in Compliance & Coding

CommunityCare HMO Inc.; Tulsa (OK); On-site; USD 65,000 - 90,000; Full time

Job summary

CommunityCare HMO Inc. seeks a Risk Adjustment Auditor to review medical records and ensure accurate capture of diagnoses per CMS guidelines and ICD-10-CM standards. The role supports risk score accuracy, regulatory compliance, and program integrity.

You will perform bi-directional reviews, identify coding gaps, and provide actionable findings to coding teams and leadership while maintaining HIPAA compliance and meeting production goals.

Qualifications

• 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.
• Experience with Medicare Advantage and ACA payer audits preferred.
• Strong knowledge of CMS-HCC and ICD-10-CM guidelines.

Responsibilities

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

Skills

CMS-HCC knowledge

ICD-10-CM knowledge

RADV requirements

Attention to detail

Analytical thinking

Communication skills

Independent worker

Deadline driven

Strong organizational skills

Compliance & integrity

Education

Bachelor's degree in Health Information Management or related field

Certified Professional Coder (CPC)

CRC certification

CCS certification

Tools

EMR systems

Microsoft Excel

Job description

CommunityCare HMO Inc. seeks a Risk Adjustment Auditor to review medical records and ensure accurate capture of diagnoses per CMS guidelines and ICD-10-CM standards. The role supports risk score accuracy, regulatory compliance, and program integrity.

You will perform bi-directional reviews, identify coding gaps, and provide actionable findings to coding teams and leadership while maintaining HIPAA compliance and meeting production goals.