Risk Adjustment - Risk Adjustment Auditor 135-2032

CommunityCare, Inc.; Tulsa (OK); On-site; USD 60,000 - 85,000; Full time

Job summary

CommunityCare, 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.

The role includes chart reviews, identifying coding gaps, delivering audit findings to coding teams, and supporting compliance initiatives while maintaining HIPAA confidentiality.

Qualifications

• Two years minimum 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 internal audit programs or payer audits preferred
• 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

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 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.

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.