Risk Adjustment Provider Auditor

About the position

The Risk Adjustment Provider Auditor position is an impactful provider facing role that evaluates and manages the accuracy of risk adjustment reporting. This position will access the appropriateness of documentation and coding completed by our participating providers through targeted audits, medical record reviews and procedural reviews. They will utilize their strong knowledge base of clinical, medical coding and auditing to ensure accurate risk adjustment reporting. The Risk Adjustment Provider Auditor will be responsible for reviewing medical record documentation, creating audit reports, sharing results with providers, identifying areas of improvement and engaging providers in performance improvement plans, if necessary. They will also identify trends in coding/documentation and work closely with provider educators to develop intervention strategies. Additionally, this role will be responsible for completing internal oversight reviews of the risk adjustment process and provide feedback to department leaders on regulatory documents published by CMS.

Responsibilities

• Serve as a subject matter expert (SME) both internally and externally regarding appropriate coding standards to ensure an accurate reflection of the current health status of our members.
• Develop a provider auditing program to include identification of policies and procedures, audit reporting and corrective action plan processes.
• Create a robust reporting process for providers to include but not limit to educational opportunities, workflow best practices and action planning to ensure improvement in condition documentation and ICD-10-CM coding.
• Responsible for collaboration with data analytics team to identify outliers in coding data, analyze this data, develop an auditing plan, complete provider audits, and communicate findings and next steps.
• Complete face-to-face discussions with participating providers regarding their performance on completed audits.
• Develop specialized goals for providers, assisting them in implementing performance changes within their clinic(s) and following up and reporting on goals.
• Develop and implement an annual Risk Adjustment oversight program, in which policies and standard operating procedures are reviewed for completeness and correct utilization. Complete an oversight report and assist the department in identifying areas of risk and mitigation plans.
• Report to appropriate compliance and/or VBC teams results of audits and facilitate and report on any provider related corrective active plans. This will include coordination between contracting, legal and compliance.
• Maintain current knowledge of ICD-10-CM codes, CMS HCC model and updates, CMS documentation requirements and coding guidelines, and state and federal regulations.

Requirements

• Bachelor's degree in nursing, health information management, or other health care field.
• Minimum of three (3) years of experience in medical record review, diagnosis coding, clinical education, and/or auditing.
• Previous experience with ICD-10-CM coding.
• CRC (Certified Risk Adjustment Coder) is required for this role, CPMA (certified Professional Medical Auditor) a plus but not required. Note: AHIMA comparable certifications (CCA, CCS, or CDIP) will be considered.
• An equivalent combination of education and experience may be substituted for this requirement.
• The ability to meet or exceed the attendance and timeliness requirements of their departments.
• The ability to work well in a team environment and be capable of building and maintaining positive relationships with other staff, departments, and customers.

Nice-to-haves

• Previous experience with Medicare and/or commercial risk adjustment guidelines, rules and regulations.
• Registered Nurse (RN) license.
• Previous experience/understanding of electronic medical and health records.
• Previous experience in completing medical record audits and providing feedback.
• Prior experience teaching/training others on correct coding guidelines and can present to large groups of providers/clinicians, including physicians.
• Previous risk adjustment experience.
• Previous experience CMS/HHS regulatory publications.
• Previous experience completing oversight reviews on department procedures.