This position operates on a hybrid work schedule. Candidate must reside in Los Angeles or Orange County.
Are you ready to make a lasting impact and transform the healthcare space? We are one of Southern California’s fastest-growing Medicare Advantage plans with an incredible 112% year-over-year membership growth.
Who Are We? ✨
Clever Care was created to meet the unique needs of the diverse communities we serve. Our innovative benefit plans combine Western medicine with holistic Eastern practices, offering benefits that align with our members’ culture and values.
Why Join Us?
We’re on a mission! Our rapid growth reflects our commitment to making healthcare accessible for underserved communities. At Clever Care, you’ll have the opportunity to make a real difference, shape the future of healthcare, and be part of a fast-moving, game-changing organization that celebrates diversity and innovation.
Job Summary
The Risk Adjustment Coding Auditor is responsible for conducting retrospective and prospective coding audits, diagnosis validation reviews, provider documentation assessments, and compliance monitoring activities to support accurate Medicare Advantage risk adjustment reporting and CMS audit readiness. This role reviews medical record documentation and ICD-10-CM diagnosis coding to ensure compliance with CMS Risk Adjustment program requirements, Official Coding Guidelines, AHA Coding Clinic guidance, and organizational policies.
The Risk Adjustment Coding Auditor serves as a subject matter expert in HCC coding, diagnosis validation, provider documentation improvement, and risk adjustment compliance. The position supports enterprise risk adjustment initiatives through audit activities, RADV preparedness, chart review validation, vendor oversight, provider education, and continuous quality improvement efforts aimed at enhancing coding accuracy, documentation integrity, and risk score accuracy.
Functions & Responsibilities
- Conduct retrospective, prospective, and targeted coding audits to assess the accuracy, completeness, and compliance of ICD-10-CM diagnosis coding and HCC capture.
- Review medical record documentation to validate reported diagnoses and ensure adherence to CMS Risk Adjustment data submission requirements and M.E.A.T. documentation standards.
- Perform diagnosis validation and deletion reviews to identify unsupported, inaccurately coded, or insufficiently documented conditions.
- Conduct second-level quality assurance reviews and root cause analysis related to coding accuracy, documentation quality, chart retrieval processes, provider workflows, and vendor performance.
- Support CMS RADV audit readiness activities, including chart validation reviews, mock audits, record retrieval efforts, and documentation reconciliation.
- Identify trends, compliance risks, and audit findings through analysis of coding, documentation, provider, and vendor performance data.
- Perform focused reviews of high-risk HCCs, OIG-targeted conditions, and other areas of elevated audit risk.
- Analyze audit outcomes and develop actionable recommendations to improve coding accuracy, documentation quality, and compliance performance.
- Develop and maintain audit methodologies, quality assurance protocols, audit tools, and compliance monitoring processes.
- Deliver provider and staff education related to risk adjustment coding, documentation best practices, diagnosis validation, and CMS compliance requirements.
- Conduct provider meetings and on-site or virtual educational sessions to review audit findings, documentation deficiencies, coding opportunities, and corrective actions.
- Monitor vendor and provider audit performance and support corrective action plans, remediation efforts, and continuous improvement initiatives.
- Collaborate with Risk Adjustment, Quality, Compliance, Provider Relations, Clinical Operations, and external partners to address coding and documentation issues.
- Prepare audit reports, provider scorecards, compliance summaries, executive dashboards, and leadership presentations.
- Serve as a subject matter expert on CMS Risk Adjustment methodology, HCC coding, RADV audits, documentation standards, and regulatory requirements.
- Maintain current knowledge of CMS regulations, ICD-10-CM coding updates, risk adjustment methodology changes, audit trends, and industry best practices.
- Perform other duties as assigned.
Qualifications
Education and Experience:
- Bachelor's degree in Health Information Management, Nursing, Healthcare Administration, Public Health, or a related discipline; equivalent combination of education and experience may be considered.
- Minimum of five (5) years of experience in Medicare Advantage Risk Adjustment, HCC coding, coding audits, compliance auditing, provider education, or related healthcare auditing functions.
- Minimum of three (3) years of experience conducting risk adjustment coding audits and diagnosis validation reviews.
- Health plan, Medicare Advantage Organization (MAO), MSO, IPA, physician group, or risk-bearing entity experience strongly preferred.
- Experience supporting CMS RADV audits, chart review programs, validation projects, or compliance monitoring activities preferred.
- Demonstrated experience delivering provider documentation improvement (PDI) and coding education.
- Advanced knowledge of CMS Risk Adjustment methodology, ICD-10-CM coding guidelines, HCC models, and medical necessity documentation requirements.
- One of more of the following certifications are required: Certified Professional Coder (CPC), Certified Coding Specialist (CCS), Certified Coding Specialist–Physician-Based (CCS-P), Certified Risk
Adjustment Coder (CRC), Certified Professional Medical Auditor (CPMA), Registered Health Information Technician (RHIT), Registered Health Information Administrator (RHIA)
Skills & Competencies
- Strong knowledge of CMS Risk Adjustment methodology, HCC coding models, ICD-10-CM coding guidelines, and Medicare Advantage regulations.
- Expertise in diagnosis validation, medical record auditing, provider documentation review, and coding compliance.
- Ability to accurately identify supported, unsupported, and insufficiently documented diagnoses.
- Thorough understanding of M.E.A.T. criteria, clinical documentation requirements, and diagnosis reporting standards.
- Knowledge of RADV audit methodologies, audit risk areas, and compliance monitoring practices.
- Strong analytical, investigative, and critical-thinking skills with the ability to identify trends, root causes, and opportunities for improvement.
- Ability to interpret clinical documentation and apply coding guidelines consistently and accurately.
- Excellent written and verbal communication skills with the ability to effectively present audit findings and education to providers, vendors, and leadership.
- Strong organizational and project management skills with the ability to manage multiple priorities and deadlines.
- Proficiency in Microsoft Office Suite, including Excel, Word, PowerPoint, and Outlook.
- Experience with risk adjustment, coding audit, EMR, and analytics platforms preferred.
- Ability to work independently and collaboratively in a fast-paced, cross-functional environment.
- Commitment to regulatory compliance, data integrity, confidentiality, and continuous quality improvement.
Wage Range: $72,800 to $80,000 per year
Physical & Working Environment.
Physical requirements needed to perform the essential functions of the job, with or without reasonable accommodation:
- Must be able to travel when needed or required
- Ability to operate a keyboard, mouse, phone and perform repetitive motion (keyboard); writing (note-taking)
- Ability to sit for long periods; stand, sit, reach, bend, lift up to fifteen (15) lbs.
Ability to express or exchange ideas to impart information to the public and to convey detailed instructions to staff accurately and quickly.
Work is performed in an office environment and/or remotely. The job involves frequent contact with staff and public. May occasionally be required to work irregular hours based on the needs of the business.
Clever Care Health Plan is proud to be an Equal Employment Opportunity and Affirmative Action workplace. Individuals seeking employment will receive consideration for employment without regard to race, color, national origin, religion, age, sex (including pregnancy, childbirth or related medical conditions), sexual orientation, gender perception or identity, age, marital status, disability, protected veteran status or any other status protected by law. A background check is required.
Salary ranges posted on the job posting are based on California wages. Salary may be higher or lower depending on the candidate’s state residency.
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