Senior Risk Adjustment Auditor – Health Plan

Job not on LinkedIn

🔥 3 hours ago

🗿 South Dakota, Wisconsin – Remote

🗿 South Dakota – Remote 🧀 Wisconsin – Remote

💵 $31 - $49 / hour

⏰ Full Time

🟠 Senior

🔎 Auditor

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Sanford Health

WebsiteLinkedInAll Job Openings

10,000+ employees

Founded 1894

🛡️ Insurance

🏥 Healthcare

⚕️ Healthcare Insurance

Insurance • Healthcare • Healthcare Insurance

Sanford Health is the largest rural health system in the United States, dedicated to transforming the healthcare experience and providing access to world-class healthcare in America's heartland. Headquartered in Sioux Falls, South Dakota, Sanford Health serves over 1. 4 million patients and nearly 200,000 health plan members across 250,000 square miles. The integrated health system includes 48 medical centers, 211 clinic locations, and more than 160 senior living centers, employing 2,900 physicians and advanced practice providers. Sanford Health is committed to offering compassionate care through its Centers of Excellence, focusing on specialties such as cancer, orthopedics, women’s health, and genetics. Additionally, it provides affordable health insurance, engages in extensive clinical trials, and supports personalized genetic medicine.

📋 Description

• Support overall outcomes and daily activities for Risk Adjustment Data Validation (RADV) audits • Conduct targeted quality assurance audits • Oversee vendor quality assurance reviews • Perform internal coding team quality assurance • Develop, implement, and deliver provider and clinical staff education and training resources • Apply expertise in HCC documentation, audit rules, risk adjustment operations, and clinical knowledge • Review medical charts, claims, and enrollment data supporting diagnosis codes submitted to governmental entities • Identify quality issues in risk adjustment processes through chart review, data investigations, and EMR expertise • Conduct root cause analysis and share findings in a timely, organized manner • Present conclusions to providers, vendors, data teams, and senior leaders • Provide coding quality assurance and educational support for Medicare Advantage, ACA/Exchange, and Medicaid risk adjustment methodologies • Support internal monitoring and regulatory readiness activities, including RADV and other regulatory audits • Collaborate with department analysts on relevant data operations • Perform other related duties as assigned

🎯 Requirements

• Associate degree required; Bachelor’s degree preferred • Minimum of 5 years of HCC coding and auditing for Risk Adjustment • Intermediate understanding of RADV protocols and procedures • Intermediate understanding of retrospective and prospective risk adjustment • Basic familiarity with Microsoft suite, including Excel • Working knowledge of Epic or similar EHR preferred • Strong knowledge of CMS HCC model, hierarchy, and relative HCC values • Certified Risk Adjustment Coder (CRC), Certified Professional Coder (CPC), or relevant equivalent required • Unencumbered RN license with the State Board of Nursing where nursing practice occurs and/or multistate licensure in an NLC state preferred • Ability to obtain and maintain required department-specific competencies and certifications

🏖️ Benefits

• Full-time schedule • Day shift • 40 scheduled weekly hours • EEO/AA protections • Disability accommodation support for the application process