Medical Coding Auditor - Risk Adjustment

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The Medical Coding Auditor plays a crucial role in ensuring the accuracy and compliance of diagnostic coding within medical records. This position is essential for maintaining the integrity of Risk Adjustment and HCC coding. By leveraging a deep understanding of ICD-10 and other coding standards, the auditor reviews and researches provider diagnostic coding issues, performs detailed medical record reviews, and highlights documentation standards. This role also identifies opportunities for improving provider performance related to coding errors and documentation deficiencies. In addition to auditing, the Medical Coding Auditor conducts quality assurance (QA) reviews of peer and vendor coders to ensure coding accuracy, adherence to service level agreements, and performance guarantees. Feedback is provided where discrepancies are found, fostering a culture of continuous improvement.

What you’ll do:

• Analyze medical claims data and associated documentation to ensure accurate and complete diagnostic risk capture. Document findings, including diagnosis changes and opportunities for documentation improvement, and recognize trends.
• Evaluate coding and documentation behavior, providing recommendations for provider improvement.
• Interpret and apply policy and coding standards (e.g., Coding Clinic) that impact financial and operational aspects of risk adjustment coding.
• Collaborate and communicate effectively with internal and external sources (auditors, vendors, and peers) to deliver QA findings, clearly articulating rationale supported by industry-standard evidence.
• Maintain current knowledge of coding applications for ICD-10 and other applicable coding standards.
• Perform other duties as assigned.

What you’ll bring:

• Bachelor's degree or four (4) years of relevant work experience (Required)
• Three (3) years of experience as a RHIA, RHIT, or CPC certified coder within a healthcare provider organization or health insurance company (Required)
• Current certification as a professional coder (RHIA, RHIT, or CPC) (Required)
• CRC certification or willingness to obtain it within the first year of employment.
• Additional certifications such as CCSP, CCS-H, CPC-P, and CPH-H are desirable.
• Nursing or other clinical experience is a plus.

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