Medicare Risk Adjustment Compliance Auditor (CPC, CCS, or CCS-P Required) (Remote)

Summary

Alignment Health is committed to serving seniors and people with chronic and complex health needs while transforming health care. The Remote Risk Adjustment Compliance Auditor conducts provider- and coder-level reviews and audits to ensure accurate risk adjustment data submission to CMS, maintains compliance tracking tools, monitors corrective action plans, and supports RADV and other risk adjustment audits.

Responsibilities

• Monitors coding prevalence reporting for coding outliers
• Reviews IPA Policies and procedures to ensure programs are compliant
• Monitors internal coding staff accuracy percentages to ensure they are tracked and maintained
• Monitors coding vendor’s accuracy percentages to ensure the coding accuracy and quality of the data submitted to CMS
• Works with Risk Adjustment Management on any data validation and /or RADV coding audit(s) to ensure completeness and coding accuracy of all submissions to CMS
• Maintains a comprehensive tracking and management tool for Risk Adjustment Compliance
• Ensures compliance with all applicable federal, state & and local regulations, as well as institutional/organizational standards, practices, policies & procedures
• Works with Risk Adjustment Management to monitor HCC Corrective Action Plans as needed
• Suggests customizations of Risk Adjustment education for support staff, PCPs, specialists, employees, contracted employees and central departments
• Utilizes, protects, and discloses Alignment Healthcare patients’ protected health information (PHI) only in accordance with Health Insurance Portability and Accountability Act (HIPAA) standards
• Maintains professional and technical knowledge by attending educational workshops, reviewing professional publications, establishing personal networks and participating in professional societies
• Contributes to team effort by accomplishing related results as needed
• Represents the department in RADV and other risk adjustment related audits
• Other duties as assigned to meet the organization’s needs

Skills

• • Required: Minimum 3 years of professional coding experience in a medical group or health plan setting
• • Required: Bachelor's degree in business administration, health care management or in a related field or 4 years additional experience in lieu of education
• • Required: Certified Coder required - CPC, CCS & CCS-P
• * Experience with strategic planning in risk mitigation
• * Previous use of Epic, Allscripts, EZCap a plus
• * Proficient user in MS office suite, MS access a plus
• * Ability to communicate positively, professionally and effectively with others; provide leadership, teach and collaborate with others
• * Effective written and oral communication skills; ability to establish and maintain a constructive relationship with diverse members, management, employees and vendors
• * Mathematical Skills:  Ability to perform mathematical calculations and calculate simple statistics correctly
• * Reasoning Skills:  Ability to prioritize multiple tasks; advanced problem-solving; ability to use advanced reasoning to define problems, collect data, establish facts, draw valid conclusions, and design, implement and manage appropriate resolution
• * Problem-Solving Skills:  Effective problem solving, organizational and time management skills and ability to work in a fast-paced environment
• * Report Analysis Skills:  Comprehend and analyze statistical reports
• • Required: Certified Coder required - CPC, CCS & CCS-P
• 1.  While performing the duties of this job, the employee is regularly required to talk or hear. The employee regularly is required to stand, walk, sit, use hand to finger, handle or feel objects, tools, or controls; and reach with hands and arms
• 2. The employee frequently lifts and/or moves up to 10 pounds. Specific vision abilities required by this job include close vision and the ability to adjust focus
• • Preferred: Certified Auditor

Qualifications

Must Haves

• • Required: Minimum 3 years of professional coding experience in a medical group or health plan setting
• • Required: Bachelor's degree in business administration, health care management or in a related field or 4 years additional experience in lieu of education
• • Required: Certified Coder required - CPC, CCS & CCS-P
• * Experience with strategic planning in risk mitigation
• * Previous use of Epic, Allscripts, EZCap a plus
• * Proficient user in MS office suite, MS access a plus
• * Ability to communicate positively, professionally and effectively with others; provide leadership, teach and collaborate with others
• * Effective written and oral communication skills; ability to establish and maintain a constructive relationship with diverse members, management, employees and vendors
• * Mathematical Skills:  Ability to perform mathematical calculations and calculate simple statistics correctly
• * Reasoning Skills:  Ability to prioritize multiple tasks; advanced problem-solving; ability to use advanced reasoning to define problems, collect data, establish facts, draw valid conclusions, and design, implement and manage appropriate resolution
• * Problem-Solving Skills:  Effective problem solving, organizational and time management skills and ability to work in a fast-paced environment
• * Report Analysis Skills:  Comprehend and analyze statistical reports
• • Required: Certified Coder required - CPC, CCS & CCS-P
• 1.  While performing the duties of this job, the employee is regularly required to talk or hear. The employee regularly is required to stand, walk, sit, use hand to finger, handle or feel objects, tools, or controls; and reach with hands and arms
• 2. The employee frequently lifts and/or moves up to 10 pounds. Specific vision abilities required by this job include close vision and the ability to adjust focus

Nice to Haves

• • Preferred: Certified Auditor

Benefits

• Fully remote work arrangement
• Ample room for growth and innovation