[Hiring] Medicare Risk Adjustment Compliance Auditor @Alignment Health

Role Description

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 action 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.

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

Qualifications

• Required: Minimum 3 years of professional coding experience in a medical group or health plan setting.
• Preferred: None.

Requirements

• 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.

Benefits

• 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.