Risk Adjustment Compliance Auditor (Remote)

Overview

A healthcare organization focused on serving seniors and chronically ill populations is seeking a remote Risk Adjustment Compliance Auditor. This role supports auditing and compliance activities related to risk adjustment data submitted to CMS, including provider and coder-level audits, medical record documentation review, coding accuracy verification, and compliance risk identification. The position involves collaboration with Risk Adjustment leadership and cross-functional teams to ensure coding accuracy, regulatory compliance, audit readiness, and corrective action follow-through.

Responsibilities

• Monitor coding prevalence reporting, internal trends, and coding outliers to support compliance and audit readiness.
• Review IPA policies and procedures to ensure program compliance.
• Track and maintain accuracy percentages for internal coding staff and coding vendors.
• Collaborate with Risk Adjustment Management on data validation and RADV coding audit activities, including review of audit outcomes and coding accuracy of CMS submissions.
• Maintain and develop audit tracking, reporting, and management tools related to Risk Adjustment Compliance.
• Ensure compliance with federal, state, and local regulations, as well as organizational standards and policies.
• Monitor HCC corrective action plans and follow-up activities related to audit findings.
• Suggest customizations for Risk Adjustment education for support staff, PCPs, specialists, employees, contracted employees, and central departments.
• Handle protected health information (PHI) in accordance with HIPAA standards.
• Stay current on CMS audit processes, risk adjustment regulations, and industry best practices through ongoing education and professional development.
• Participate actively in RADV and other risk adjustment-related audits and compliance activities.
• Perform other duties as assigned to meet organizational needs.

Requirements

• Minimum 3 years of professional coding experience in a medical group or health plan setting.
• Bachelor’s degree in business administration, healthcare management, or related field; or 4 years additional experience in lieu of degree.
• Certified Coder credential required (CPC, CCS, or CCS-P).
• Experience with strategic planning in risk mitigation.
• Proficient in MS Office suite; experience with MS Access is a plus.
• Previous use of Epic, Allscripts, EZCap is a plus.
• Strong communication skills, both written and oral, with ability to collaborate and provide leadership.
• Ability to perform mathematical calculations and analyze statistical reports.
• Advanced problem-solving, organizational, and time management skills.
• Ability to prioritize multiple tasks and work effectively in a fast-paced environment.

Preferred Qualifications

• Certified Auditor credential preferred.

Physical Requirements

• Regularly required to talk, hear, stand, walk, sit, use hands and fingers, and reach with hands and arms.
• Frequently lifts and/or moves up to 10 pounds.
• Requires close vision and ability to adjust focus.
• Reasonable accommodations may be made for individuals with disabilities.

Schedule

• Full-time, Monday through Friday.
• Initial training primarily aligned with Pacific Time business hours.
• Flexible working hours available post-training based on business needs and team collaboration.

Compensation & Benefits

• Pay range: $64,384.00 - $96,577.00 annually.
• Pay may vary based on market location, education, responsibilities, and experience.

Location

• Remote position.

Equal Opportunity

The employer is an Equal Opportunity/Affirmative Action organization. All qualified applicants will receive consideration without regard to race, color, religion, sex, national origin, disability, age, protected veteran status, gender identity, or sexual orientation.