Senior Risk Adjustment Auditor

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🕒 June 26

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HonestHealth, Inc

WebsiteLinkedInAll Job Openings

1 - 10 employees

Founded 2009

HonestHealth provides a unique combination of content and and technical expertise to support organizations from conceptualization to technical development of health care cost and quality transparency initiatives. We advise on data collection, measure selection, visualization as well as provide design, front-end and back-end development, database management, and hosting.

📋 Description

• Audit third-party vendor coding and CDI outputs to ensure accuracy, compliance, and adherence to contracted performance standards • Audit internal CDI Specialist I and II work, including chart reviews, queries, and reconciliation activities • Identify coding inaccuracies, unsupported diagnoses, missed HCC opportunities, and documentation gaps • Deliver audit findings, trend analysis, and corrective action recommendations to CDI leadership and vendor partners • Track and report audit performance metrics to support continuous quality improvement initiatives. • Review completed encounters in the post-visit, pre-billing window to validate documentation completeness and coding accuracy • Review and audit Pre-visit plan coding and CDI • Evaluate alignment between medical record documentation and draft claims, ensuring proper HCC capture • Assess each diagnosis for appropriate ICD-10-CM specificity and MEAT criteria compliance • Prioritize high-impact conditions and risk-adjustable diagnoses for intervention and resolution • Ensure compliant query practices aligned with AHIMA and ACDIS standards • Review query quality, provider responses, and documentation updates to confirm clinical support for diagnoses • Validate final alignment between documentation and submitted claims, resolving discrepancies in partnership with coding and billing teams • Translate audit findings into targeted provider and team education on documentation, coding specificity, and risk adjustment compliance • Partner with CDI, coding, and leadership teams to improve workflows, policies, and audit readiness • Serve as a subject matter expert and resource on risk adjustment, CDI best practices, and audit standards • Support the evolution of CDI and audit processes as automation, EMR integrations, and vendor models mature • Identify opportunities to expand audit scope (e.g., documentation patterns, provider performance trends, process inefficiencies) • Contribute to the development of scalable audit frameworks and quality assurance methodologies • Deliver real-time and aggregate coding and documentation feedback to providers and their clinical support teams • Design and facilitate education sessions on ICD-10-CM specificity, chronic condition documentation, HCC coding, and risk adjustment compliance both virtually and, on occasion, in person • Perform other related responsibilities as assigned

🎯 Requirements

• Associate’s or Bachelor’s degree in Health Information Management, Nursing, or a related clinical field (or equivalent experience) • 5+ years of experience in risk adjustment, medical coding, CDI, or auditing • 2+ years of experience in prospective and concurrent review risk adjustment coding and auditing • Direct experience with Medicare Advantage (Part C) risk adjustment models and HCC coding required • Experience auditing vendor-delivered work and/or CDI programs preferred • One or more of the following certifications: CRC (Certified Risk Adjustment Coder) and CPC (Certified Professional Coder) are required • CCS (Certified Coding Specialist) or CCDS (Certified Clinical Documentation Specialist) is preferred • RHIT/RHIA is preferred • Advanced knowledge of ICD-10-CM Official Guidelines and AHA Coding Clinic guidance • Advanced technical expertise in risk adjustment and coding compliance • Strong understanding of CMS risk adjustment methodologies and HCC models • Expertise in MEAT criteria application and compliant query practices • Familiarity with CDI workflows, EMR systems, and coding/audit tools • Strong analytical skills with the ability to identify patterns, risks, and improvement opportunities • High attention to detail and commitment to accuracy and compliance • Ability to collaborate effectively across CDI, coding, vendor management, and provider teams • Ability to translate complex audit findings into clear, actionable insights • Effective communication and collaboration skills across clinical and non-clinical stakeholders • Ability to manage multiple priorities in a fast-paced, evolving environment • Ability to work independently in a remote environment • Willingness to travel up to 25% for provider education or team collaboration • Commitment to maintaining confidentiality and compliance with all regulatory requirements.

🏖️ Benefits

• Eligible for short-term incentives • Comprehensive benefits package