Risk Adjustment Audit Reviewer

Job title: Risk Adjustment Audit Reviewer

Location: Phoenix, Arizona (Remote)

Alternate location: California, Colorado, Nevada, Nebraska, Wyoming

Role Overview

This position will serve as a coding compliance resource for Risk Adjustment initiatives. The role involves reviewing audit findings, providing education on identified opportunities, and offering objective supporting documentation to support findings. The focus is on compliance with CMS regulations, Medicare Advantage, and coding standards, including auditing internal coders and preparing for CMS audits.

Key Responsibilities

• Review audit findings and provide education on identified opportunities.

• Communicate effectively with leaders, peers, and vendors.

• Utilize deep knowledge of ICD-10-CM coding and risk adjustment guidelines.

• Immediately report adverse audit trends and potential areas of risk to leadership.

• Provide education to internal staff based on audit findings.

• Effectively communicate the audit process and results to appropriate leaders.

• Audit all vendor risk adjustment activity.

• Adhere to stringent timelines consistent with project deadlines.

• Required Qualifications

• Education: Must possess current knowledge of Healthcare/Coding as normally obtained through the completion of a bachelor’s degree in healthcare administration or related field, or equivalent experience in a related field.

• Experience: Four years of coding or audit experience, including two years of Risk Adjustment Coding. Knowledge of outpatient and inpatient guidelines is required.

• Skills: Deep understanding of ICD-10 Coding Guidelines, CMS Risk Adjustment guidelines, Anatomy/Physiology, the disease process, and medical terminology. Strong organizational and interpersonal skills, including the ability to deliver difficult information positively. Certified Professional Coder (CPC) OR American Health Information Management Association (AHIMA) certification is required.

• Preferred Qualifications

• Certified Risk Adjustment Coder (CRC) certification.

• Previous risk adjustment auditing experience and/or experience with provider education.

• Experience with health plans is helpful.

• Everforth Apex is a world-class IT services company that serves thousands of clients across the globe. When you join Everforth Apex, you become part of a team that values innovation, collaboration, and continuous learning. We offer quality career resources, training, certifications, development opportunities, and a comprehensive benefits package. Our commitment to excellence is reflected in many awards, including ClearlyRateds Best of Staffing in Talent Satisfaction in the United States and Great Place to Work in the United Kingdom and Mexico.

• Everforth Apex uses a virtual recruiter as part of the application process. Click here for more details. By applying for this job, you agree to receive calls, AI-generated calls, text messages, or emails from Everforth Apex and its affiliates, and contracted partners. Frequency varies for text messages. Message and data rates may apply. Carriers are not liable for delayed or undelivered messages. You can reply STOP to cancel and HELP for help. You can access our privacy policy at https://www.apexsystems.com/privacy-policy

• Everforth Apex

Benefits

• Overview: Everforth Apex offers a range of supplemental benefits, including medical, dental, vision, life, disability, and other insurance plans that offer an optional layer of financial protection. We offer an ESPP (employee stock purchase program) and a 401K program which allows you to contribute typically within 30 days of starting, with a company match after 12 months of tenure. Everforth Apex also offers a HSA (Health Savings Account on the HDHP plan), a SupportLinc Employee Assistance Program (EAP) with up to 8 free counseling sessions, a corporate discount savings program and other discounts. In terms of professional development, Everforth Apex hosts an on-demand training program, provides access to certification prep and a library of technical and leadership courses/books/seminars once you have 6+ months of tenure, and certification discounts and other perks to associations that include CompTIA and IIBA. Everforth Apex has a dedicated customer service team for our Consultants that can address questions around benefits and other resources, as well as a certified Career Coach. You can access a full list of our benefits, programs, support teams and resources within our ‘Welcome Packet’ as well, which an Everforth Apex team member can provide.

• Everforth Apex Systems is an equal opportunity employer. We do not discriminate or allow discrimination on the basis of race, color, religion, creed, sex (including pregnancy, childbirth, breastfeeding, or related medical conditions), age, sexual orientation, gender identity, national origin, ancestry, citizenship, genetic information, registered domestic partner status, marital status, disability, status as a crime victim, protected veteran status, political affiliation, union membership, or any other characteristic protected by law. Everforth Apex will consider qualified applicants with criminal histories in a manner consistent with the requirements of applicable law.

• UnitedHealthcare creates and publishes the Transparency in Coverage Machine-Readable Files on behalf of Everforth Apex Systems.