Risk Adjustment Auditor Educator

Collaborative Health Systems
US - South Carolina - Anderson
July 3, 2024

You could be the one who changes everything for our 28 million members. Centene is transforming the health of our communities, one person at a time. As a diversified, national organization, you'll have access to competitive benefits including a fresh perspective on workplace flexibility.

Position Purpose: Conduct provider medical record audits, analysis of practice coding patterns, education and training regarding risk adjustment to ensure accurate CMS payment and improve quality of care. Analysis of MRA data to identify patterns and development of interventions at the provider and market level.
Subject matter experts for proper risk adjustment coding and CMS data validation

Work in conjunction with other departments to include Provider Relations, Quality as well as the Medical Director for the state assigned to ensure compliance of CMS risk adjustments guidelines are met.

Analyze MRA data to identify patterns and development of interventions at the provider and market level to coordinate an educational work plan for WellCare contracted providers.

Conduct provider education and training regarding risk adjustment to help to ensure accurate CMS payment and to improve quality of care.

This includes training venues such as provider offices, hospitals, webinars, conference calls, email correspondence, etc.

Works on additional risk adjustment audit requests (i.e. outside auditors' requests).

Serves on the RADV Committee as subject matter experts.

Perform quality assurance auditing (i.e. ensure appropriateness and accuracy of ICD-9/ICD-10 coding) for WellCare's Medical Coding Specialists.

Communicates QA results to the Medical Coding Specialists with suggestions for improvement and re-training topics.

Perform other duties as necessary.

Additional Responsibilities:
Performs other duties as assigned

Complies with all policies and standards
Education/Experience: Bachelor's degree or equivalent experience required

Candidate Experience: 5+ years of experience in a hospital, a physician setting or a Managed Care Organization as a medical coder
2+ years of experience in coding with knowledge of Medicare risk adjustment (HCC Coding)
Required Other experience in teaching, training or an educator/instructor role required; but provider education experience is preferred
Preferred Other managed care experience

Licenses and Certifications: A license in one of the following is required:

Required Other One of the following certifications are required at the time of hire: CPC or CCS
Required Other CPMA is required within the first year of employment
Required Other CRC required on the second year of employment

For Arizona Complete Health: 2+ years of experience in a hospital, a physician setting, or a Managed Care Organization as a medical coder is required. 1+ years of experience in medical records coding (HCC Coding) with knowledge of Medicare, Marketplace, and Medicaid risk adjustment is required. Provider education experience is preferred.

Licenses and Certifications: One of the following certifications is required at the time of hire:
CPC, CPC-H, CPC-P, CRC, CCS, CCS-P, RHIT, RHIA or CPMA. CRC is required within the first year of employment. CPMA is preferred on the second year of employment.

For Collaborative Health Systems: Required 5+ years of experience in a hospital, a physician setting or a Managed Care Organization as a medical coder
Required 2+ years of experience in coding with knowledge of Medicare risk adjustment (HCC Coding)
Preferred Other managed care experience.

One of the following licensures required at hire: CPC or CCS
CRC required within the 1st year of employment
CPMA preferred on the 2nd year of employmentPay Range: $54,000.00 - $97,100.00 per year Centene offers a comprehensive benefits package including: competitive pay, health insurance, 401K and stock purchase plans, tuition reimbursement, paid time off plus holidays, and a flexible approach to work with remote, hybrid, field or office work schedules. Actual pay will be adjusted based on an individual's skills, experience, education, and other job-related factors permitted by law. Total compensation may also include additional forms of incentives.
Centene is an equal opportunity employer that is committed to diversity, and values the ways in which we are different. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, veteran status, or other characteristic protected by applicable law.

Read the full job description and apply online on the recuiter's web-site

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