Quality Assurance Risk Adjustment Auditor I
Cambria Health, Inc.
Quality Assurance Risk Adjustment Auditor I
Remote opportunity within WA,OR, ID or UT
Primary Job Purpose
The Quality Assurance Risk Adjustment Auditor performs quality reviews of internal and vendor coding on first-pass retrospective/prospective chart review utilizing various types of records to ensure accurate risk adjustment reporting. This role is also responsible for performing second level reviews of all new HCCs identified through the first-pass retrospective/prospective chart review process. Identifies trends in internal and vendor risk adjustment reporting and makes those trends known to leadership as well as coding team supervisor and training lead to develop intervention strategies.
General Functions and Outcomes
Performs Retrospective and Prospective chart reviews to ensure accurate risk adjustment reporting.
Performs quality reviews of vendor coding in support of the risk adjustment process.
Verifies and ensures the accuracy, completeness, specificity and appropriateness of provider-reported diagnosis codes based on medical record documentation.
Reviews medical record information to identify complete and accurate diagnosis code capture based on CMS HCC and HHS HCC categories.
Identifies trends in first-pass coding and documentation and partners with coding team supervisor and training lead to develop intervention strategies.
Supports and actively participates in process and quality improvement initiatives.
Maintains knowledge of relevant regulatory mandates and ensures activities are in compliance with requirements.
Consistently meets departmental performance and attendance requirements.
Assists with special projects such as risk mitigation reviews.
Serves as subject matter resource regarding the risk adjustment process and diagnosis coding for risk adjustment.
Monitors and interprets regulatory changes that may impact administration of the Risk Adjustment Program. Assists with implementation activities as a result of regulatory changes to the Program.
Assists with HHS-RADV audits.
Demonstrates ability to perform accurate and complete chart reviews for risk adjustment.
Demonstrates ability to perform quality audits of internal and vendor coding.
Knowledge of and adherence to Official ICD-9-CM/ICD-10-CM Coding Guidelines.
Demonstrates analytical ability to identify problems, develop solutions, and implement actions in a timely manner.
Demonstrates ability to identify and communicate trends in risk adjustment coding and documentation.
Demonstrates proficient PC skills and familiarity with corporate software, such as Word, Excel and Outlook.
Effective verbal and written communication skills.
Knowledge of health systems operations, including an understanding of reimbursement methodologies and coding conventions for governmental and commercial products.
Advanced knowledge and understanding of risk adjustment, coding, and documentation requirements.
Experience in HHS-RADV audits preferred.
Normally to be proficient in the competencies listed above
Quality Assurance Risk Adjustment Auditor would have an Associate degree in Healthcare or related field and three years of experience in clinical coding or auditing or equivalent combination of education and experience. Coding Certification (CCA, CCS, CCS-P, CPC, CRC or CPC-P) required. Risk Adjustment experience is required. HCC or Inpatient coding experience preferred.
Required Licenses, Certifications, Registration, Etc.
CCA, CCS, CCS-P, CPC, CRC or CPC-P
The expected hiring range for a Quality Assurance Risk Adjustment Auditor I is $60,000 to $82,000 depending on skills, experience, education, and training; relevant licensure / certifications; performance history; and work location. The bonus target for this position is 10%. The current full salary range for this role is $56,500 to $92,500.
Base pay is just part of the compensation package at Cambia that is supplemented with an exceptional 401(k) match, bonus opportunity and other benefits. In keeping with our Cause and vision, we offer comprehensive well-being programs and benefits, which we periodically update to stay current. Some highlights:
medical, dental, and vision coverage for employees and their eligible family members
annual employer contribution to a health savings account ($1,200 or $2,500 depending on medical coverage, prorated based on hire date)
paid time off varying by role and tenure in addition to 10 company holidays
up to a 6% company match on employee 401k contributions, with a potential discretionary contribution based on company performance (no vesting period)
up to 12 weeks of paid parental time off (eligible day one of employment if within first 12 months following birth or adoption)
one-time furniture and equipment allowance for employees working from home
up to $225 in Amazon gift cards for participating in various well-being activities. for a complete list see our External Total Rewards page.
We are an Equal Opportunity and Affirmative Action employer dedicated to workforce diversity and a drug and tobacco-free workplace. All qualified applicants will receive consideration for employment without regard to race, color, national origin, religion, age, sex, sexual orientation, gender identity, disability, protected veteran status or any other status protected by law. A background check is required.