Risk Adjustment Compliance Auditor Lead

Job Number: 2520

Workplace Type:

Position Title: Risk Adjustment Compliance Auditor Lead

External Description:

Alignment Healthcare was founded with a mission to revolutionize health care with a serving heart culture. Through its unique integrated care delivery models, deep physician partnerships and use of proprietary technologies, Alignment is committed to transforming health care one person at a time.

We believe that great work comes from people who are inspired to be their best. We have built a team of talented and experienced people who are passionate about transforming the lives of the seniors we serve. In this fast-growing company, you will find ample room for growth and innovation alongside the Alignment community.

 

Position Summary:
Lead the provider and coder level reviews for the Compliance coding staff as well as oversees audits to ensure accurate risk adjustment data is being submitted to CMS. Accountable for the develop and maintain tracking tools, review and audit outcomes / findings and monitor any corrective active plans implemented due to review or audit findings. Monitor internal reporting for outliers, stay up to date with CMS audit processes and actively participate in all audits as they relate to risk adjustment.

 

General Duties/Responsibilities:

(May include but are not limited to)

• Monitors Compliance coding staff’s productivity and program initiatives
• Establish performance guidelines in terms of quality
• Keep team updated on new statues/ regulations. Polices and distribute updates as required
• Lead program cadences in conjunction with the Sr. Director of MRA Compliance
• Provides guidance in the coding / abstraction, quality and reporting.
• Monitors coding prevalence reporting for coding outliers.
• Review IPA Policies and procedures to ensure programs are compliant.
• Monitor internal coding staff accuracy percentages ensure they are tracked and maintained.
• Monitor coding vendor’s accuracy percentages to ensure the coding accuracy and quality of the data submitted to CMS.
• Work with Risk Adjustment Management on any Data Validation and /or RADV coding audit(s) to ensure completeness and coding accuracy of all submissions to CMS.
• Maintain a comprehensive tracking and management tool for Risk Adjustment Compliance.
• Ensures compliance with all applicable federal, state and local regulations, as well as with institutional/organizational standards, practices, policies & procedures.
• Work with Risk Adjustment Management on the monitoring of HCC Corrective Action Plans as needed.
• Assist in coordination of Risk Adjustment audit activities
• Assist with CMS Data Validation activities, including suggested record selections, tracking and submission, in conjunction with Risk Adjustment Healthcare Management
• Suggest customizations of Risk Adjustment education for various audiences, support staff, PCPs, specialists, employees vs. contracted and Central Departments

• Stay current of industry coding, compliance and HCC issues.

• Utilize, protect, and disclose Alignment Healthcare patients’ protected health information (PHI) only in accordance with Health Insurance Portability and Accountability Act (HIPAA) standards.
• Maintain professional and technical knowledge by attending educational workshops; reviewing professional publications; establishing personal networks; and participating in professional societies.
• Contribute to team effort by accomplishing related results as needed.
• Contributes to team effort by accomplishing related results as needed.
• Represents the department in RADV and other risk adjustment related audits.
• Other duties as assigned to meet the organization’s needs.

 

Minimum Requirements:

To perform this job successfully, an individual must be able to perform each essential duty satisfactorily.  The requirements listed below are representative of the knowledge, skill, and/or ability required.  Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

 

1. Minimum Experience:
   1. Three to five years of coding in a medical group or health plan setting required; Professional Coding experience required.
   2. Previous use of Epic, Allscripts, EZCap a plus
   3. Proficient user in MS office suite, MS access a plus
2. Education/Licensure:
   1. Bachelor’s degree in Business Administration, health Care Management or in a related field or equivalent experience desired.
   2. Certified Coder required, CPC, CCS, CCS-P, Certified Auditor a plus.
3. Other:
   1. Experience with strategic planning in risk mitigation.

1. Work Environment:
2. 1. The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job.  Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

 

Essential Physical Functions:

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

 

1. While performing the duties of this job, the employee is regularly required to talk or hear. The employee regularly is required to stand, walk, sit, use hand to finger, handle or feel objects, tools, or controls; and reach with hands and arms.
2. The employee frequently lifts and/or moves up to 10 pounds. Specific vision abilities required by this job include close vision and the ability to adjust focus.

 

Alignment Healthcare, LLC is proud to practice Equal Employment Opportunity and Affirmative Action. We are looking for diversity in qualified candidates for employment: Minority/Female/Disable/Protected Veteran.

If you require any reasonable accommodation under the Americans with Disabilities Act (ADA) in completing the online application, interviewing, completing any pre-employment testing or otherwise participating in the employee selection process, please contact [email protected].

City: Orange

State: California

Location City: Orange

Location State: California

Community / Marketing Title: Risk Adjustment Compliance Auditor Lead

Company Profile:

By leveraging our world-class technology platform, innovative care delivery models, deep physician partnerships and our serving heart culture, Alignment Health is revolutionizing health care for seniors! From member experience professionals and clinicians, to data scientists and operations leaders, we have built a talented and passionate team that is deeply committed to our mission of transforming health care for the seniors we serve. Ready to join us?

At Alignment, delivering exceptional care to seniors starts with ensuring an exceptional experience for our over 1,300 employees. At the center of our employee experience is a culture where employees at all levels and across all teams are encouraged to share their unique ideas and perspectives. After all, when you can bring your authentic self to work, whether that’s in a clinical setting, our corporate office or a home office, creativity and innovation flourish! Another important part of the Alignment culture is a belief in continuous learning and growth. As a result, in this fast-growing company, you will find ample support to grow your skills and your career – with us.

EEO Employer Verbiage:

 

Please note: All clinical positions are contingent upon successful engagement with Alignment Health’s COVID-19 Vaccination program (fully vaccinated with documented proof or approved exception/deferral).

Alignment Health is an Equal Opportunity/Affirmative Action Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, disability, age, protected veteran status, gender identity, or sexual orientation.

*DISCLAIMER: Please beware of recruitment phishing scams affecting Alignment Health and other employers where individuals receive fraudulent employment-related offers in exchange for money or other sensitive personal information. Please be advised that Alignment Health and its subsidiaries will never ask you for a credit card, send you a check, or ask you for any type of payment as part of consideration for employment with our company. If you feel that you have been the victim of a scam such as this, please report the incident to the Federal Trade Commission at https://reportfraud.ftc.gov/#/. If you would like to verify the legitimacy of an email sent by or on behalf of Alignment Health’s talent acquisition team, please email [email protected].