Risk Adjustment Auditor III (Coding Certification Required)

Job Summary:

The Risk Adjustment Auditor III is responsible for conducting initial retrospective chart audit, documents discrepancies, identifies accurate coding opportunities, and conducts provider education.

Essential Functions:

• Demonstrates a thorough understanding of Risk Adjustment coding for all risk adjusted products including hierarchical condition categories (HCCs)
• Participates in quality coding initiatives as appropriate or assigned
• Maintains knowledge of AHA Coding Clinic and ICD-CM (ICD-10) Official Guidelines for Coding and Reporting, and possesses the ability to share this knowledge with providers including physicians and other patient care team members in a compliant, professional, and concise manner
• Code and recheck all diagnoses and procedures using ICD-CM (and ICD-10) and CPT-4 codes adhering to all official coding guidelines, federal and state regulations, health system and departmental policies and productivity standards
• Performs over-reads on vendor and other auditor coding
• Assesses providers’ documentation to determine if it meets applicable guidelines to support the diagnoses selected
• Assist in preparation and implementation of necessary internal controls for related entities consistent with CMS and State requirements and to support RADV or other regulatory audits
• Use results of audits to prepare and deliver feedback to provider/provider office staff for all LOBs in any of CareSource’s markets
• Develops provider education using MS Office products such as PowerPoint, Word, Excel, etc. 
• Uses data to identify trends, compliance risks
• Knowledgeable and experienced in researching documentation from CMS, Coding Clinic, ICD-10 books, AAPC, AHIMA, and other sites for Risk Adjustment guidance
• Perform any other job duties as requested

Education and Experience:

• Bachelor’s Degree or equivalent years of relevant work experience in healthcare insurance field is required
• Minimum of five (5) years of diagnostic coding or relevant experience and a firm understanding of ICD-10 coding guidelines
• A minimum of five (5) years of experience in auditing medical records or relevant experience is required
• Risk Adjustment coding experience is preferred

Competencies, Knowledge and Skills:

• Strong skills working with MS Office products: Microsoft Word, Microsoft Power Point, Microsoft Excel
• Superior communication skills needed to convey complex ICD-10 guidelines to network physicians and their staffs
• Capable of using technology to conduct webinars to large physician and coder audiences
• Exceptional knowledge of medical coding, billing systems and regulatory requirements
• Knowledgeable of Medicaid, Medicare, Exchange
• Knowledgeable of ICD-10 and CPT codes
• Strong analytical and decision making skills
• Wide degree of creativity to educate providers and their staffs about how to document and submit accurate and complete risk adjustment data
• Strong …