Risk Adjustment Auditor

Network Health's success is rooted in its mission to create healthy and strong Wisconsin communities. Network Health is seeking a Risk Adjustment Auditor to join our team. This individual, in collaboration with the director, will be responsible for performing and overseeing the RA audits as mandated by CMS and HHS on a regular basis.

The Risk Adjustment Auditor oversees the Network Health Risk Adjustment auditing efforts. The Auditor conducts clinical based audits for identifying and submitting documented diagnoses to CMS/HHS for members of the Medicare Advantage and ACA qualified product(s). The Risk Adjustment Auditor is responsible for the coordination and completion of NH's annual Initial Validation Audit (IVA) conducted by CMS/HHS and all CMS Risk Adjustment Data Validation Audits (RADV). This is accomplished through collaboration with department leadership in oversight, completion, and accurate reporting of risk adjustment clinical data to CMS/HHS. The position interacts with both internal and external customers including vendors, administration, practitioner office and hospital staff. The Auditor is responsible for the oversight and management of the Risk Adjustment audit program.

Location: Candidates must reside in the state of Wisconsin for consideration. This position is eligible to work at your home office (reliable internet is required). Travel to the corporate office in Menasha will be required occasionally for the position, including on first day.

Hours: 1.0 FTE, 40 hours per week, 8am-5pm Monday through Friday.

Check out our 2024 Annual Report video to learn a little more about the difference our employees make in the communities we live and work in. As an employee, you will have the opportunity to work hard and have fun while getting paid to volunteer in your local neighborhood. You too, can be part of the team and making a difference. Apply to this position to learn more about our team.

Job Responsibilities:

• Coordinates and performs internal and external risk adjustment audits, including mandated CMS and HHS annual audits.
• Develop review and maintain NH's risk adjustment audit process and policy documents to ensure complete and accurate coding and data submission of NH/NHIC Medicare Advantage and ACA-qualified members
• Develop and maintain a compliant external audit review plan, to include the auditing and managing of contracted vendor activities.
• Maintain a thorough knowledge and understanding of CMS/HHS-HCC Risk Adjustment models, rules and guidelines.
• Perform medical record reviews by reviewing documentation against supporting information in the medical record, claims data and coding information.
• Assist in the development and performance of NH's risk adjustment audit strategy, policies and procedures to meet compliance requirements for the defined population.
• Assist with identifying opportunities, as well as providing guidance and suggestions for quality and performance improvements in the collection and recording of documentation.
• May work with physicians and staff to improve medical record documentation and coding. May assist with the development of training programs and tools to address the educational needs of providers and non-clinical staff.

Job Requirements:

• Associate Degree or equivalent experience required.
• 5+ years' experience working in HCC coding, auditing and/or risk adjustment operations required.
• 1+ years of experience working in an HHS/ACA risk adjustment-based coding role required.
• Prior risk adjustment IVA and/or RADV audit experience required.
• Certified Coder credentials required (CPC, COC, CIC, or AHIMA certification).
• Certified Risk Adjustment Coder (CRC) credentials strongly preferred.

Network Health is Equal Opportunity Employer.