Risk Adjustment - Risk Adjustment Auditor 135-2032

JOB SUMMARY: The Risk Adjustment Auditor is responsible for reviewing medical records and related documentation to ensure accurate capture of diagnoses in compliance with CMS risk adjustment guidelines and ICD-10-CM coding standards. This role plays a critical part in supporting accurate risk score calculation, regulatory compliance, and overall program integrity. KEY RESPONSIBILITIES: • Perform bi-directional retrospective and prospective medical record reviews to validate, clarify, and accurately capture risk adjusted diagnoses (HCCs) in accordance with CMS guidelines and MEAT documentation requirements. • Ensure documentation supports coded conditions in accordance with ICD-10-CM, CMS, and payer-specific guidelines. • Identify unsupported diagnoses, over coding, under-coding, and documentation gaps. • Provide detailed audit findings and recommendations to coding teams, providers, and leadership. • Monitor compliance with CMS Risk Adjustment Data Validation (RADV) standards. • Track and report audit results, trends, and performance metrics. • Collaborate with coding staff, providers, and operations teams to improve documentation quality and coding accuracy. • Assist with education and training initiatives related to risk adjustment and documentation best practices. • Maintain confidentiality and ensure compliance with HIPAA regulations. • Meet daily and weekly productivity goals and quality standards set by the supervisor. • Perform other job-related duties as required or assigned. QUALIFICATIONS: • Knowledge of CMS-HCC and HHS-HCC risk adjustment model. • Knowledge of ICD-10-CM coding guidelines. • Knowledge of RADV requirements. • Proficiency in EMR systems and Microsoft Office (Excel preferred). • High attention to detail. • Strong analytical and critical thinking skills. • Clear written and verbal communication. • Ability to work independently and meet deadlines. • Strong organizational skills. • Integrity and commitment to compliance. • Successful completion of Health Care Sanctions background check. EDUCATION/EXPERIENCE: • A minimum of two years of risk adjustment coding or auditing experience. • Experience reviewing medical records across multiple specialties. • Certified Professional Coder (CPC), CRC, CCS, or equivalent coding certification. • Bachelor’s degree in Health Information Management or related field preferred. • Previous auditing experience in Medicare Advantage and ACA preferred. • Experience with internal audit programs or payer audits preferred.