[Hiring] Senior Risk Adjustment Auditor @Sanford Health

Role Description

The Senior Risk Adjustment Auditor must have broad clinical knowledge and a strong understanding of Risk Adjustment operations, including experience coding for both the ACA and Medicare Advantage markets. This position will be responsible for overall outcomes and daily activities supporting Risk Adjustment Data Validation (RADV) audits, targeted quality assurance audits, vendor quality assurance oversight, internal coding team quality assurance, provider and clinical staff education, and other risk adjustment projects.

• Applies expertise in HCC documentation, audit rules, risk adjustment operations, and general clinical knowledge.
• Increases the accuracy and completeness of initiatives, including RADV audits, retrospective and prospective audits, vendor quality assurance reviews, and provider and clinical staff education.
• Accountable for the successful development, implementation, and delivery of educational and training resource materials to assist providers in coding accuracy.
• Works independently with a high degree of autonomy.
• Collaborates with department analyst(s) on relevant data operations.
• Reviews medical charts, claims, and enrollment data that support diagnosis codes reported on claims.
• Proactively identifies existing and potential quality issues in all risk adjustment processes.
• Conducts root cause analysis and shares findings in a timely and organized manner.
• Professionally presents conclusions to a diverse audience, including providers, vendors, data teams, and senior leaders.
• Provides overall educational support and coding quality assurance activities to internal and external stakeholders.
• Trains others on best practices, guidelines, and regulations of medical coding.
• Supports internal monitoring and regulatory readiness activities, including RADV and other regulatory audits.
• Other related duties may be assigned.

Qualifications

• Associate required, Bachelor’s preferred.
• Minimum of 5 years HCC coding and auditing for Risk Adjustment required.
• Required experience with:
  • Intermediate understanding of RADV protocols and procedures.
  • Intermediate understanding of retrospective and prospective risk adjustment.
  • Basic familiarity with Microsoft suite, including Excel.
• Working knowledge of Epic or similar EHR preferred.
• Experience discussing HCC coding and clinical details with all provider types.
• Strong knowledge of CMS HCC model, hierarchy, and relative HCC values required.
• Certified Risk Adjustment Coder (CRC), Certified Professional Coder (CPC), or relevant equivalent is required.
• Currently holds an unencumbered RN license with the State Board of Nursing where the practice of nursing is occurring and/or possesses multistate licensure if in a Nurse Licensure Compact (NLC) state (preferred).
• Obtains and subsequently maintains required department-specific competencies and certifications.

Requirements

• Broad clinical knowledge and understanding of Risk Adjustment operations.
• Experience coding for ACA and Medicare Advantage markets.
• Ability to work independently and collaboratively.
• Strong presentation and communication skills.

Benefits

• Competitive salary range: $31.00 - $49.50.
• Comprehensive health benefits.
• Opportunities for professional development.