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Risk Mitigation Coding Auditor

United States

JOB DESCRIPTION

Risk Mitigation Coding Auditor

Lead I – BPM

Who we are:

Advantasure is a growing company and a member of the UST HealthProof family, Advantasure champions innovative solutions with an eye on the future—providing health plans with the flexibility to adapt to a changing regulatory environment and evolving business needs. Leveraging the industry’s leading experts in government-sponsored health plans, Advantasure offers solutions for administrative cost management, quality patient outcomes and experiences, enrollment growth, risk adjustment, and quality and provider engagement initiatives.

We achieve this mission together through teamwork, communication, collaboration, and focus. Our employees are our greatest assets, and we invite you to apply to be a part of our journey toward making a difference in healthcare in the United States.

You are:

The Risk Mitigation Coding Auditor will assist with risk mitigation and government audits. This position requires the candidate to have a proficient level of understanding of risk adjustment coding, coding guidelines, and CMS/ HHS regulatory guidance. The auditor will use their knowledge to conduct audits, on behalf of clients, to validate MA and ACA risk adjustable HCCs that were previously reported, by a provider, to ensure the support of Risk adjustable HCC diagnoses in line with CMS and client guidelines.

The Opportunity:

• Ensure compliance with all applicable federal, state, and county laws and regulations related to coding and documentation guidelines for Medicare and ACA Risk adjustment
• Conduct EDPS/RAPS submission audits by diagnosis codes submitted by CMS Acceptable Physicians Specialty types for Risk Adjustment data submission
• Validate diagnosis codes to ensure adherence with ICD-10-CM and CMS guidelines.
• Perform Government audits on MA and ACA lines of business
• Perform medical record audits on behalf of health plans, to ensure documentation supports submitted CMS and HHS Hierarchical Condition Categories (HCC) conditions for the Commercial and Medicare Risk Adjustment Payment system.
• Perform medical record reviews to capture all relevant diagnosis codes included in the CMS and HHS hierarchical condition categories (HCC), focusing to close gaps and add HCC codes not yet reported for the payment year.
• Keep current on Medicare and HHS risk adjustment models and maintain up-to-date coding knowledge by reviewing materials, and attending departmental meetings and educational events, either disseminated and/or recommended by clients and managers.
• Contribute to the quality improvement activities of the department and the organization
• Make corrections (additions and deletions) as needed to ensure accurate submission of HCC codes to CMS
• Independently organize and prioritize work to ensure the completion of audit timeframes

This position description identifies the responsibilities and tasks typically associated with the performance of the position. Other relevant essential functions may be required.

What you need:

• High School diploma or GED equivalent required.
• Bachelor’s degree in a related field preferred.
• A relevant combination of education and experience may be considered in lieu of a degree.
• Certificate/License (CPC, COC, CRC, CCS-P CCS, CDEO, or CPMA) required.
• Continuous learning, as defined by the Company’s learning philosophy, is required.
• Certification or progress toward medical auditor certification is highly preferred and encouraged
• A minimum of 5 years of HCC-specific coding is required.
• Minimum of 1 year Risk adjustment auditing required.
• Understanding of CMS and ACA HCC Risk Adjustment coding and data validation requirements, and 1 year of CMS and HHS RADV audit experience in health plan operations is preferred.
• knowledge of RADV audits and Risk Adjustment.
• Strong analytical, planning, problem-solving, verbal, and written skills to communicate complex ideas.
• Ability to develop project management, meeting process, and presentation skills.
• Strong ability to work independently and direct the efforts of others.
• Strong knowledge and use of existing software packages (PowerPoint, Excel, Word, etc.).
• Ability to work independently, within a team environment, and communicate effectively with employees and clients at all levels.

Compensation can differ depending on factors including but not limited to the specific office location, role, skill set, education, and level of experience. As required by local law, UST provides a reasonable range of compensation for roles that may be hired in California, Colorado, New York City, or Washington as set forth below.

Role Location: Range of Starting Pay for Role

Remote: $50,000-$70,000

Our full-time, regular associates are eligible for 401K matching, and vacation accrual and are covered from day 1 for paid sick time, healthcare, dental, vision, life, and disability insurance benefits. Depending on the role, some associates may also be eligible for stock options.

What we believe:

We’re proud to embrace the same values that have shaped UST and its subsidiaries since the beginning. Since day one, we’ve been building enduring relationships and a culture of integrity. And today, it’s those same values that are inspiring us to encourage innovation from everyone to champion ersity and inclusion and place people at the center of everything we do.

Humility: We will listen, learn, be empathetic, and help selflessly in our interactions with everyone.

Humanity: Through business, we will better the lives of those less fortunate than ourselves.

Integrity: We honor our commitments and act with responsibility in all our relationships.

Equal Employment Opportunity Statement

UST HealthProof is an Equal Opportunity Employer.

All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, or status as a protected veteran.

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