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 presentation skills in person and virtually
• Ability to effectively interface with staff, clinicians and management
• Ability to work with others and work independently
• Possesses critical thinking/listening skills
• Facets training/knowledge is preferred

Licensure and Certification:

• AAPC or AHIMA coding certification is required

Working Conditions:

• Travel requirements: Travel 25% of time to and from provider offices
• General office environment: May be required to sit or stand for extended periods of time

Compensation Range:

CareSource takes into consideration a combination of a candidate’s education, training, and experience as well as the position’s scope and complexity, the discretion and latitude required for the role, and other external and internal data when establishing a salary level. In addition to base compensation, you may qualify for a bonus tied to company and individual performance. We are highly invested in every employee’s total well-being and offer a substantial and comprehensive total rewards package.

Compensation Type (hourly/salary):

Organization Level Competencies

• Create an Inclusive Environment

• Cultivate Partnerships

• Develop Self and Others

• Drive Execution

• Influence Others

• Pursue Personal Excellence

• Understand the Business

This job description is not all inclusive. CareSource reserves the right to amend this job description at any time. CareSource is an Equal Opportunity Employer. We are dedicated to fostering an inclusive environment that welcomes and supports individuals of all backgrounds.