Risk Adjustment - Risk Adjustment Auditor 135-2032

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

Job Summary

The Risk Adjustment Auditor is responsible for reviewing medical records and related documentation to ensure accurate capture of diagnoses in compliance with CMS risk adjustment guidelines and ICD-10-CM coding standards. This role plays a critical part in supporting accurate risk score calculation, regulatory compliance, and overall program integrity.

Key Responsibilities

• Perform bi-directional retrospective and prospective medical record reviews to validate, clarify, and accurately capture risk adjusted diagnoses (HCCs) in accordance with CMS guidelines and MEAT documentation requirements.
• Ensure documentation supports coded conditions in accordance with ICD-10-CM, CMS, and payer-specific guidelines.
• Identify unsupported diagnoses, over coding, under-coding, and documentation gaps.
• Provide detailed audit findings and recommendations to coding teams, providers, and leadership.
• Monitor compliance with CMS Risk Adjustment Data Validation (RADV) standards.
• Track and report audit results, trends, and performance metrics.
• Collaborate with coding staff, providers, and operations teams to improve documentation quality and coding accuracy.
• Assist with education and training initiatives related to risk adjustment and documentation best practices.
• Maintain confidentiality and ensure compliance with HIPAA regulations.
• Meet daily and weekly productivity goals and quality standards set by the supervisor.
• Perform other job-related duties as required or assigned.

Qualifications

• Knowledge of CMS-HCC and HHS-HCC risk adjustment model.
• Knowledge of ICD-10-CM coding guidelines.
• Knowledge of RADV requirements.
• Proficiency in EMR systems and Microsoft Office (Excel preferred).
• High attention to detail.
• Strong analytical and critical thinking skills.
• Clear written and verbal communication.
• Ability to work independently and meet deadlines.
• Strong organizational skills.
• Integrity and commitment to compliance.
• Successful completion of Health Care Sanctions background check.

Education/Experience

• 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.
• Previous auditing experience in Medicare Advantage and ACA preferred.
• Experience with internal audit programs or payer audits preferred.

CommunityCare is an equal opportunity at will employer and does not discriminate against any employee or applicant for employment because of age, race, religion, color, disability, sex, sexual orientation or national origin