Risk Adjustment Coding Auditor

CareersSign InCreate AccountRisk Adjustment Coding AuditorHuntington Beach Office - Huntington Beach, CA 92647ApplyOverviewSalary Range$72,800.00 - $80,000.00 SalaryPosition TypeFull TimeApplyDescriptionThis 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...