Risk Adjustment Auditor

Summary

Oscar is a health insurance company built around a full-stack technology platform and a focus on serving its members. The Associate, Risk Adjustment Auditor conducts internal and external quality audits of ICD-10 code abstraction, validates clinical documentation, reports audit trends, supports compliance activities, and implements process improvements and provider education resources.

Responsibilities

• Responsible for daily operations pertaining to Risk Adjustment including but not limited to: medical record reviews to report ICD-10-CM diagnosis codes for ACA and MA lines of business, potential Centers of Medicare & Medicaid Services (CMS), Health and Human Services (HHS) audits and medical record retrieval efforts
• Mitigate risk by validating Encounter Data Gathering Environment Server (EDGE) data is supported within provider encounter documentation
• Review the performance of the Risk Adjustment Coding team and report audit trends to Leadership in a timely, consistent and effective manner to ensure the appropriate changes and education are implemented
• Maintain compliance with national standards and coding practices set by the ICD-10-CM coding guidelines for accuracy, as well as compliance with Risk adjustment production standards
• Conduct CMS audits of Risk Adjustment activities, including but not limited to Risk Adjustment Data Validation audits
• Develop relationships with key individuals to foster an increased understanding of the Risk Adjustment process
• Identify and execute on the creation of clinical document improvement resources for provider education in both MA and ACA line of business
• Manage the implementation process improvements that will maximize risk adjustment factor increases
• Compliance with all applicable laws and regulations
• Other duties as assigned

Skills

• Bachelor's degree in a relevant field of study or commensurate work experience
• Certified professional coder (CPC)
• 3+ year(s) retrospective risk adjustment coding experience
• 1+ year(s) experience Quality Auditing and/or Risk Adjustment Data Validation Audit (RADV) experience
• Certified Risk Adjustment Coder (CRC) or similar certification
• Experience coding in a variety of different Electronic Medical Record (EMR) systems

Qualifications

Must Haves

• Bachelor's degree in a relevant field of study or commensurate work experience
• Certified professional coder (CPC)
• 3+ year(s) retrospective risk adjustment coding experience
• 1+ year(s) experience Quality Auditing and/or Risk Adjustment Data Validation Audit (RADV) experience

Nice to Haves

• Certified Risk Adjustment Coder (CRC) or similar certification
• Experience coding in a variety of different Electronic Medical Record (EMR) systems

Benefits

• Employee benefits
• Oscar's unlimited vacation program
• Annual performance bonuses
• Medical benefits
• Dental benefits
• Vision benefits
• 11 paid holidays
• Paid sick time
• Paid parental leave
• 401(k) plan participation
• Life insurance
• Disability insurance
• Paid wellness time and reimbursements
• Remote position