[Hiring] Senior Medical Quality Auditor Risk Adjustment @Florida Blue

Role Description

The Senior Risk Adjustment Quality Auditor utilizes their expertise and industry standard coding guidelines in performing quality accuracy audits for both internal Companies Coders and external Vendors, Partners, and Provider Groups, ensuring the accuracy of ICD-10 coding and claims data for CMS/HHS risk adjustment data submissions. The Senior Risk Adjustment Quality Auditor shall assist Leadership with the quality audit processes, identify trends and opportunities for training and education. This position shall utilize critical thinking skills and effective communication to ensure coding compliance and oversight of same.

Qualifications

• 4+ years related work experience or equivalent combination of transferable experience in Risk Adjustment Coding, Auditing, Coding Accuracy experience and/or Provider Education
• Related Bachelor’s degree or additional related equivalent work experience
• Demonstrated knowledge of CMS and HHS Risk Adjustment Programs
• Experience resolving escalated issues and barriers
• Excellent communication and collaboration skills both with internal and external audiences
• Knowledge of health plan operations
• Knowledge of provider operations
• CRC (Certified Risk Adjustment Coder from AAPC) Upon Hire
• At least one of the following upon hire:
  • CPC (Certified Professional Code from AAPC)
  • COC (Certified Outpatient Coder from AAPC)
  • CIC (Certified Inpatient Coder from AAPC)
  • CCS (Certified Coding Specialist from AHIMA)
  • CCS-P (Certified Coding Specialists Physician Based from AHIMA)

Requirements

• Execute audit procedures as outlined by Leadership including perform and document findings of quality accuracy reviews/quality audits of coding and documentation completed by Companies Internal Risk Adjustment Coders/Auditors to ensure consistency and accuracy of ICD-10 coding and industry standards.
• Advise Companies Internal Coders/Auditors on proper code selection, documentation guidelines as well as assist with training and education.
• Research and communicate ICD-10, Coding Clinics, and other industry standard guidance, when appropriate, for facilitating quality review findings and education.
• Perform and document findings of quality accuracy reviews/quality audits of coding and documentation completed by External Vendors, Partners and/or Provider Groups to ensure consistency and accuracy of ICD-10 coding.
• Research and communicate ICD-10, Coding Clinics, and other industry standard guidance, when appropriate, for facilitating quality accuracy reviews/quality audits findings.
• Communicate with external Vendors, Partners and/or Provider Groups to share out audit results and educational materials.
• Escalates trends in quality accuracy reviews/quality audits findings to Leadership and provide suggested corrective actions.
• Assists Leadership and resources to support audit scope, deadlines, and objectives.
• Assist Leadership with improvements to the quality accuracy reviews/quality audits process, identifying risks, evaluating controls, and preparing documentation.
• Assists in developing, maintaining, and updating departmental procedures, workflows, and other work tools/job aides.

Benefits

• Medical, dental, vision, life and global travel health insurance
• Income protection benefits: life insurance, short- and long-term disability programs
• Leave programs to support personal circumstances
• Retirement Savings Plan including employer match
• Paid time off, volunteer time off, 10 holidays and 2 well-being days
• Additional voluntary benefits available; and a comprehensive wellness program
• Competitive pay as well as opportunities for incentive or commission compensation
• Regular annual reviews with pay for performance considerations for base pay increases