Supervisor, Risk Adjustment Quality Assurance and Auditing

Excellus BCBS; Town of De Witt (NY); Hybrid; USD 72,000 - 129,000; Full time

Benefits offered by this job

Remote work opportunity

Job summary

Excellus BCBS in New York seeks a Supervisor, Risk Adjustment Quality Assurance and Auditing to oversee the Risk Adjustment QA Auditor team, ensuring accuracy, regulatory compliance, and audit quality. This role collaborates with leadership to drive continuous improvement in audit processes and coding accuracy.

You will lead training, performance management, and process improvement initiatives for internal staff, supporting CMS IPM, CON RADV, and HRADV audits as required.

Qualifications

• Five years ICD-10-CM and HCC coding experience required; familiarity with RADV and HRADV audits.
• Experience supervising or managing people and/or projects.
• Associate degree in health care related field preferred.
• CPC and CRC certifications required; other relevant certifications preferred.
• Strong knowledge of CMS/HHS guidelines and coding rules.
• Excellent written and verbal communication skills.
• Experience with EMR systems.
• Ability to travel as needed.

Responsibilities

• Provide strategic oversight to a team of Risk Adjustment Quality Assurance Auditors, ensuring all audit activities adhere to state, federal, and corporate standards.
• Direct and coordinate day-to-day operations of the Risk Adjustment QA Audit team, ensuring coding accuracy and regulatory compliance.
• Oversee RADV and HRADV audits across CMS, ICD-10-CM coding, and organizational guidelines.
• Document audit project expectations and parameters, meeting deadlines.
• Coach, mentor, and train audit staff; conduct performance evaluations and regular feedback.
• Ensure audits follow CMS guidelines and organizational policies.
• Monitor audit quality, accuracy rates, and turnaround times; review complex cases as needed.
• Identify process improvements to drive audit accuracy and productivity.

Skills

ICD-10-CM coding

HCC coding

Leadership

Communication

Project management

EMR systems

Education

Associate degree in health care

Tools

EMR systems

Job description

Job Description

The Supervisor, Risk Adjustment Quality Assurance and Auditing, is responsible for oversight of the daily operations of the Risk Adjustment Quality Assurance Auditor team. This role ensures the accuracy, compliance, and quality of the risk adjustment coding and documentation audits in alignment with regulatory requirements and organizational policies. This position provides leadership, training, and performance management to audit staff while driving continuous improvement in audit processes, coding accuracy, and operational efficiencies. The Supervisor partners with leadership on developing strategies to enhance efficiency and quality practices and to prioritize all internal, state, and federal government audits (CMS Improper Payment Measure (IPM), Contract-level Risk Adjustment Data Validation (CON RADV), and Department of Health and Human Services (HRADV) and auditor workflow.

Summary

The Supervisor, Risk Adjustment Quality Assurance and Auditing, is responsible for oversight of the daily operations of the Risk Adjustment Quality Assurance Auditor team. This role ensures the accuracy, compliance, and quality of the risk adjustment coding and documentation audits in alignment with regulatory requirements and organizational policies. This position provides leadership, training, and performance management to audit staff while driving continuous improvement in audit processes, coding accuracy, and operational efficiencies. The Supervisor partners with leadership on developing strategies to enhance efficiency and quality practices and to prioritize all internal, state, and federal government audits (CMS Improper Payment Measure (IPM), Contract-level Risk Adjustment Data Validation (CON RADV), and Department of Health and Human Services (HRADV) and auditor workflow.

Essential Accountabilities

• Provide strategic oversight, supervision, and support to a team of Risk Adjustment Quality Assurance Auditors, ensuring all audit activities strictly adhere to state, federal, and corporate standards.
• Direct and coordinate the day-to-day operations of the Risk Adjustment QA Audit team, ensuring coding accuracy, regulatory compliance, and consistent application of CMS, ICD-10-CM, and organizational guidelines.
• Oversee risk adjustment audit activity including monthly internal coding quality audits and all federal and state risk adjustment data validation audits including, but not limited to, Improper Payment Measure, Contract-level RADV, Department of Health and Human Services RADV (HRADV).
• Documents and defines audit project expectations and parameters for the Risk Adjustment Quality Assurance Auditors in keeping with department, corporate, state, and federal deadlines.
• Assists the Risk Adjustment Coding Educator Manager and Training Lead in identifying areas of opportunity for external business partners and internal coding and audit staff for coding and audit education based on internal quality assurance and state and federal audits.
• Provides coaching, mentoring, and ongoing training to audit staff to enhance coding knowledge and audit performance. Conducts performance evaluations, goal setting, and regular feedback conversations via quarterly check-ins.
• Ensure audits are conducted in accordance with CMS guidelines, ICD10-CM Official Coding Guidelines, risk adjustment coding standards, and organizational policies.
• Monitor audit quality, accuracy rates, and turnaround times. Assist in review of complex cases, as necessary.
• Serves as a subject matter expert for Risk Adjustment Audit and Coding. Advises staff on proper audit and coding practices through informal discussion and project validation.
• Evaluates day-to-day workload and processes to maximize productivity and efficiency ensuring all deadlines are met. Assists leadership verifying and reporting staff productivity, quality and assigning audit due dates, setting project expectations, and monitors staff for timely project completion.
• Develops corrective action plans, training material, and performs training as needed. Maintains staff and departmental quality and volume related statistics and provides documentation to departmental management.
• Functions as a backup quality assurance auditor for risk adjustment audit functions and assists with day-to-day work as needed. Executes audit projects in support of the Risk Adjustment Department strategy.
• Identifies and recommends the development of new processes, as necessary. Continually seeks and suggests process improvements to drive audit accuracy and productivity.
• Coordinates and performs all RADV audits and other audits as requested.
• Keeps management informed of project activities through regular written and oral status reports. Proactively identifies risks that may hinder audit success. Reports to the Manager Risk Adjustment Coding and Auditing on team and individual audit accomplishments, barriers, progress, and training needs.
• Consistently demonstrates high standards of integrity by supporting the Lifetime Healthcare Companies’ mission and values, adhering to the Corporate Code of Conduct, and leading to the Lifetime Way values and beliefs.
• Maintains high regard for member privacy in accordance with the corporate privacy policies and procedures.
• Maintains knowledge of all relevant legislative and regulatory mandates and ensures that all activities are in compliance with these requirements.
• Conducts regular staff meetings to include timely distribution and education related to departmental and Ethics/Compliance information.
• Regular and reliable attendance is expected and required.
• Performs other functions as assigned by management.

Minimum Qualifications

• Five (5) years ICD-10-CM and Hierarchical Condition Category (HCC) coding experience required and experience in CMS and HHS Risk Adjustment Data Validation Audits (RADV and HRADV).
• Prior experience supervising or managing people and/or projects or indirectly leading teams.
• Associate’s degree in a health care related field preferred.
• CPC and CRC certifications required. Other current coding certification (CPC-H, CPC-I, CCS, RHIA, or RHIT) preferred by AAPC or AHIMA.
• Certified Documentation Expert Outpatient (CDEO) preferred.
• Advanced knowledge of medical terminology, abbreviations, anatomy and physiology, major disease processes, and pharmacology. Knowledge of healthcare industry.
• Extensive knowledge of coding conventions and payment rules as they apply to medical record documentation, billing of medical services, and health care reimbursement systems. This includes a comprehensive understanding of ICD-10, and other types of coding submitted to the Health Plan by contracted facilities, and providers.
• Possess extensive knowledge of CMS and HHS HCC Risk Adjustment coding, Medicaid CRG coding, and data validation requirements.
• Strong written and verbal communication skills; strong analytical, organization and time management skills required.
• Recognizes and properly oversees confidential health information.
• Demonstrated ability to utilize a variety of Electronic Medical Records (EMR) systems.
• Demonstrated experience in project completion, educational program development, and/or group presentation.

Physical Requirements

• Ability to work prolonged periods sitting and/or standing at a workstation and working on a computer.
• Ability to work in a home office for continuous periods of time for business continuity.
• Ability to travel across the Health Plan service region for meetings and/or trainings as needed.
• Repetitive motion required.

Equal Opportunity Employer

In support of the Americans with Disabilities Act, this job description lists only those responsibilities and qualifications deemed essential to the position.

All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, or status as a protected veteran.

Compensation Range(s)

Grade E5: Minimum $71,880 - Maximum $129,384

The salary range indicated in this posting represents the minimum and maximum of the salary range for this position. Actual salary will vary depending on factors including, but not limited to, budget available, prior experience, knowledge, skill and education as they relate to the position’s minimum qualifications, in addition to internal equity. The posted salary range reflects just one component of our total rewards package. Other components of the total rewards package may include participation in group health and/or dental insurance, retirement plan, wellness program, paid time away from work, and paid holidays.

Please note: There may be opportunity for remote work within all jobs posted by the Excellus Talent Acquisition team. This decision is made on a case-by-case basis.