Risk Adjustment - Risk Adjustment Coding Auditor 135-2014

CommUnityCare; Tulsa (OK); On-site; USD 65,000 - 90,000; Full time

Job summary

CommUnityCare is seeking a Risk Adjustment Auditor to review medical records and documentation for accurate diagnosis capture in line with CMS risk adjustment guidelines and ICD-10-CM standards.

The role involves bi-directional reviews, identifying coding gaps, and collaborating with coding teams and clinicians to enhance documentation quality and compliance. Requires CPC/CRC/CCS or equivalent and at least two years of experience.

Qualifications

• Two years of risk adjustment coding or auditing experience.
• Experience reviewing medical records across multiple specialties.
• Certified coding credentials (CPC/CRC/CCS) or equivalent.
• Knowledge of CMS-HCC, ICD-10-CM guidelines, and RADV requirements.
• Proficiency with EMR systems and Microsoft Office.

Responsibilities

• Perform bidirectional retrospective and prospective medical record reviews to validate risk-adjusted diagnoses (HCCs) per CMS guidelines.
• Ensure documentation supports coded conditions per ICD-10-CM and payer guidelines.
• Identify unsupported diagnoses, over- or under-coding, and documentation gaps.
• Provide audit findings and recommendations to coding teams, providers, and leadership.
• Monitor RADV compliance and track audit results, trends, and performance metrics.
• Collaborate with coding staff, providers, and operations to improve documentation quality and coding accuracy.
• Assist with education on risk adjustment and documentation best practices.
• Maintain HIPAA confidentiality and comply with regulations.
• Meet daily and weekly productivity and quality targets.

Skills

CMS-HCC risk adjustment

ICD-10-CM guidelines

RADV requirements

Attention to detail

Analytical thinking

Communication skills

Independent work

Organizational skills

Education

Certified Professional Coder (CPC)

Certified Risk Adjustment Coder (CRC)

Certified Coding Specialist (CCS)

Bachelor’s degree in Health Information Management

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 and 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.

Location: Tulsa, OK, USA

Job Family: Commercial

Pay Type: Salary

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