Senior Risk Adjustment Auditor - Health Plan

Good Samaritan Society; Wisconsin; Hybrid; USD 43,000 - 68,000; Full time

Benefits offered by this job

Health insurance

Dental insurance

Vision insurance

Life insurance

401(k)

Time off

Job summary

The Senior Risk Adjustment Auditor at Sanford Health must have broad clinical knowledge and a strong understanding of RADV audits and HCC coding. You will review charts, claims, and enrollment data to ensure accuracy of risk adjustment submissions to CMS and DHS, and mentor staff on coding quality and regulatory readiness.

This remote WI role involves leading educational initiatives, working independently with limited supervision, and collaborating with data teams to support ACA/Medicare

Qualifications

• Minimum 5 years HCC coding and auditing for risk adjustment.
• Experience with RADV protocols and risk adjustment procedures.
• Basic familiarity with Microsoft Excel; Epic or similar EMR preferred.

Responsibilities

• Review charts, claims, and enrollment data to support coding accuracy.
• Identify quality issues and perform root cause analysis.
• Educate providers and staff on coding guidelines and CMS requirements.
• Support regulatory readiness activities and RADV audits.

Skills

HCC coding

Auditing

RADV protocols

CMS HCC model

Data analysis

Education

Associate degree

Bachelor’s preferred

Tools

Microsoft Excel

Epic EMR

Job description

Careers With Purpose

Sanford Health, the largest rural health system in the United States, is dedicated to transforming the health care experience and providing access to world-class health care in America’s heartland.

Facility: Remote WI
Location: Remote, WI
Address:
Shift: Day
Job Schedule: Full time
Weekly Hours: 40.00
Salary Range: $31.00 - $49.50

Job Summary

The Senior Risk Adjustment Auditor must have broad clinical knowledge and a strong understanding of Risk Adjustment operations, including experience coding for both the ACA and Medicare Advantage markets. This position will be responsible for overall outcomes and daily activities supporting Risk Adjustment Data Validation (RADV) audits, targeted quality assurance audits, , vendor quality assurance oversight, internal coding team quality assurance, provider and clinical staff education, and other risk adjustment projects. Applies expertise in HCC documentation, audit rules, , risk adjustment operations, and general clinical knowledge to increase the accuracy and completeness of our initiatives, including Risk Adjustment Data Validation (RADV) audits, retrospective and prospective audits, vendor quality assurance reviews, and provider and clinical staff education. Is accountable for the successful development, implementation and delivery of educational and training resource materials to assist providers in coding accuracy. Will work independently the majority of the time with a high degree of autonomy. This position will collaborate with department analyst(s) on relevant data operations.

Reviews medical charts, claims, and enrollment data that support diagnosis codes reported on claims and submitted to governmental entities, with the goal of proactively identifying existing and potential quality issues in all our risk adjustment process. Seeks understanding through chart review, data investigations, and EMR expertise, while conducting root cause analysis, share findings in a timely and organized manner, and professionally presenting conclusions to a diverse audience, potentially including providers, vendors, data teams, and senior leaders. Provides overall educational support and coding quality assurance activities to both internal and external stakeholders as it relates to Medicare Advantage, ACA/Exchange and Medicaid risk adjustment reimbursement methodologies and policies to ensure the accuracy and integrity of risk adjustment data submitted to the Centers for Medicare & Medicaid Services (CMS) and the Department of Health Services (DHS). Trains others on best practices, guidelines and regulations of medical coding. Support internal monitoring and regulatory readiness activities, including Risk Adjustment Data Validation (RADV) and other regulatory audits

Other related duties maybe be assigned.

Qualifications

Associate required, Bachelor’s preferred.

Minimum of 5 years HCC coding and auditing for Risk Adjustment required. Required experience with: intermediate understanding of RADV protocols and procedures; intermediate understanding of retrospective and prospective risk adjustment; Basic familiarity with Microsoft suite, including excel.

Working Knowledge of Epic or similar HER preferred. Experience discussing HCC coding and clinical details with all provider types with strong Knowledge of CMS HCC model, hierarchy, and relative HCC values required.

Certified Risk Adjustment Coder (CRC), Certified Professional Coder (CPC), or relevant equivalent is required

Currently holds an unencumbered RN license with the State Board of Nursing where the practice of nursing is occurring and/or possess multistate licensure if in a Nurse Licensure Compact (NLC) state (preferred.) Obtains and subsequently maintains required department specific competencies and certifications.

Benefits

Sanford offers an attractive benefits package for qualifying full-time and part-time employees. Depending on eligibility, a variety of benefits include health insurance, dental insurance, vision insurance, life insurance, a 401(k) retirement plan, work/life balance benefits, and a generous time off package to maintain a healthy home-work balance. For more information about Total Rewards, visit https://sanfordcareers.com/benefits .

Sanford is an EEO/AA Employer M/F/Disability/Vet. If you are an individual with a disability and would like to request an accommodation for help with your online application, please call 1-877-673-0854 or send an email to [e-mail] .

Sanford has a Drug Free Workplace Policy. An accepted offer will require a drug screen and pre-employment background screening as a condition of employment.

Req Number: R-0273979
Job Function: Health Plan
Featured: No