Risk Adjustment - Risk Adjustment Coding Auditor 135-2014

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

Job summary

CommunityCare HMO Inc. is seeking a Risk Adjustment Auditor to review medical records, validate diagnoses, and ensure coding accuracy per CMS guidelines. You will identify gaps, provide actionable findings, and support education across coding teams.

Strong attention to detail and knowledge of RADV requirements are essential. The role requires two years of risk adjustment coding or auditing experience, CPC/CRC/CCS credentials, and proficiency with EMR systems and Excel.

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.
• Previous auditing experience in Medicare Advantage and ACA preferred.

Responsibilities

• Review medical records and documentation to validate risk-adjusted diagnoses per CMS guidelines.
• Identify unsupported diagnoses, over-coding, under-coding, and documentation gaps.
• Provide detailed audit findings and recommendations to coding teams, providers, and leadership.
• Monitor RADV compliance and report trends and performance metrics.
• Collaborate with coding staff, providers, and operations to improve documentation quality and accuracy.
• Assist with education and training initiatives related to risk adjustment and documentation best practices.
• Maintain confidentiality and ensure HIPAA compliance.
• Meet daily and weekly productivity and quality standards set by the supervisor.
• Perform other job-related duties as required or assigned.

Skills

CMS-HCC knowledge

ICD-10-CM guidelines

RADV requirements

EMR systems

Microsoft Excel

Detail oriented

Communication

Independent work

Analytical thinking

Education

Bachelors in HIM

CPC/CRC/CCS

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