Risk Adjustment - Risk Adjustment Coding Auditor 135-2014

CommunityCare, Inc.; Tulsa (OK); Hybrid; USD 55,000 - 75,000; Full time

Job summary

CommunityCare, Inc. in Tulsa, OK is seeking a Risk Adjustment Auditor to review medical records and ensure accurate capture of diagnoses in line with CMS guidelines and ICD-10-CM standards.

This role supports accurate risk score calculations and program integrity. You will perform both retrospective and prospective reviews, identify coding gaps, and provide actionable recommendations to coders, providers, and leadership.

Qualifications

• Two years of risk adjustment coding or auditing experience.
• Certified Professional Coder (CPC), CRC, CCS, or equivalent.
• Experience reviewing medical records across multiple specialties.
• Knowledge of CMS-HCC and HHS-HCC models.
• Knowledge of ICD-10-CM coding guidelines.
• Familiarity with RADV requirements.
• Proficiency with EMR systems and MS Office (Excel preferred).
• High attention to detail.
• Strong analytical and critical thinking.
• Clear written and verbal communication.
• Ability to work independently and meet deadlines.
• Strong organizational skills.
• Integrity and commitment to compliance.
• Health Care Sanctions background check clearance.

Responsibilities

• Review medical records to validate risk adjusted diagnoses.
• Ensure documentation supports coded conditions per ICD-10-CM and CMS.
• Identify unsupported diagnoses and documentation gaps.
• Provide audit findings and recommendations to teams and leadership.
• Monitor RADV compliance and report trends.
• Collaborate with coding staff and providers to improve accuracy.
• Assist with education on risk adjustment and documentation best practices.
• Maintain HIPAA confidentiality and meet productivity targets.
• Perform other duties as assigned.

Skills

Attention to detail

Analytical and critical thinking

Written and verbal communication

Independent and deadline-driven

Organizational skills

Integrity and compliance

Education

Bachelor’s degree in Health Information Management or related field

Coding certification CPC/CRC/CCS or equivalent

Tools

EMR systems

Microsoft Office (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.