An Auditor examines records to determine the financial status of a company or organization. Inspects accounts and account books, prepares reports on the accuracy of internal financial records and accounting procedures.
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
