Medicare Risk Adjustment Compliance Auditor (CPC, CCS, or CCS-P Required)

Alignment Health is breaking the mold in conventional health care, committed to serving seniors and those who need it most: the chronically ill and frail. It takes an entire team of passionate and caring people, united in our mission to put the senior first.We have built a team of talented and experienced people who are passionate about transforming the lives of the seniors we serve. In this fast-growing company, you will find ample room for growth and innovation alongside the Alignment Health community. Working at Alignment Health provides an opportunity to do work that really matters, not only changing lives but saving them. Together.

The Remote Risk Adjustment Compliance Auditor is to conduct provider and coder level reviews and audits to ensure accurate risk adjustment data is being submitted to the CMS. Develops and maintains tracking tools, reviews and audits outcomes / findings and monitors any corrective active plans implemented due to review or audit findings. Monitors internal reporting for outliers, stays up to date with CMS audit processes and actively participates in all audits as they relate to risk adjustment.

Job Duties/Responsibilities:

1. Monitors coding prevalence reporting for coding outliers.
2. Reviews IPA Policies and procedures to ensure programs are compliant.
3. Monitors internal coding staff accuracy percentages to ensure they are tracked and maintained.
4. Monitors coding vendor’s accuracy percentages to ensure the coding accuracy and quality of the data submitted to CMS.
5. Works with Risk Adjustment Management on any data validation and /or RADV coding audit(s) to ensure completeness and coding accuracy of all submissions to CMS.
6. Maintains a comprehensive tracking and management tool for Risk Adjustment Compliance.
7. Ensures compliance with all applicable federal, state & and local regulations, as well as institutional/organizational standards, practices, policies & procedures.
8. Works with Risk Adjustment Management to monitor HCC Corrective Action Plans as needed.
9. Suggests customizations of Risk Adjustment education for support staff, PCPs, specialists, employees, contracted employees and central departments.
10. Utilizes, protects, and discloses Alignment Healthcare patients’ protected health information (PHI) only in accordance with Health Insurance Portability and Accountability Act (HIPAA) standards.
11. Maintains professional and technical knowledge by attending educational workshops, reviewing professional publications, establishing personal networks and participating in professional societies.
12. Contributes to team effort by accomplishing related results as needed.
13. Represents the department in RADV and other risk adjustment related audits.
14. Other duties as assigned to meet the organization’s needs.

Job Requirements:

Experience:

• Required: Minimum 3 years of professional coding experience in a medical group or health plan setting.

• Preferred: None.

Education:

• Required: Bachelor’s degree in business administration, health care management or in a related field or 4 years additional experience in lieu of education.

• Preferred: None.

Training:

• Required: Certified Coder required - CPC, CCS & CCS-P.

• Preferred: Certified Auditor.

Specialized Skills:

• Required:

• Experience with strategic planning in risk mitigation.
• Previous use of Epic, Allscripts, EZCap a plus.
• Proficient user in MS office suite, MS access a plus.
• Ability to communicate positively, professionally and effectively with others; provide leadership, teach and collaborate with others.
• Effective written and oral communication skills; ability to establish and maintain a constructive relationship with diverse members, management, employees and vendors;
• Mathematical Skills: Ability to perform mathematical calculations and calculate simple statistics correctly
• Reasoning Skills: Ability to prioritize multiple tasks; advanced problem-solving; ability to use advanced reasoning to define problems, collect data, establish facts, draw valid conclusions, and design, implement and manage appropriate resolution.
• Problem-Solving Skills: Effective problem solving, organizational and time management skills and ability to work in a fast-paced environment.
• Report Analysis Skills: Comprehend and analyze statistical reports.

Licensure:

• Required: Certified Coder required - CPC, CCS & CCS-P.

• Preferred: None.

Essential Physical Functions:

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

1. While performing the duties of this job, the employee is regularly required to talk or hear. The employee regularly is required to stand, walk, sit, use hand to finger, handle or feel objects, tools, or controls; and reach with hands and arms.

2. The employee frequently lifts and/or moves up to 10 pounds. Specific vision abilities required by this job include close vision and the ability to adjust focus.

Pay Range: $64,384.00 - $96,577.00

Pay range may be based on a number of factors including market location, education, responsibilities, experience, etc.

Alignment Health is an Equal Opportunity/Affirmative Action Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, disability, age, protected veteran status, gender identity, or sexual orientation.

*DISCLAIMER: Please beware of recruitment phishing scams affecting Alignment Health and other employers where individuals receive fraudulent employment-related offers in exchange for money or other sensitive personal information. Please be advised that Alignment Health and its subsidiaries will never ask you for a credit card, send you a check, or ask you for any type of payment as part of consideration for employment with our company. If you feel that you have been the victim of a scam such as this, please report the incident to the Federal Trade Commission at If you would like to verify the legitimacy of an email sent by or on behalf of Alignment Health’s talent acquisition team, please email .

Originally posted on Himalayas