Risk Adjustment - Risk Adjustment Coding Auditor 135-2014

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

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.

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