Risk Adjustment Auditor

Wellvana
US - Tennessee - Nashville
October 12, 2024

The Why Behind Wellvana:

The healthcare system isn't designed for health. We're designed to change that.

We're Wellvana, and we help doctors deliver life-changing healthcare.

Through our high-touch approach to value-based care, we're moving beyond fee-for-service and helping tie the healthy outcomes of patients directly to healthier profitability for providers and health systems.

Providers in our curated network keep their independence, reduce their administrative headaches, and spend more time with patients. Patients, in turn, get an elevated experience with coordinated care that is nothing short of life changing.

Named a Best Place to Work by Nashville Business Journal and featured in Insider's 33 startups "investors expect to take off in 2023," we're one of the fastest-growing companies in America because what we do works.

This is the way medicine is meant to be.

Clarity on the Role:

This remote auditing position will report directly to the Coding Audit Manager. This role requires the ability to perform ongoing internal quality assurance audits of in-house coders, providers, and outside vendors as assigned. These audits will be used to set companywide objectives/goals, identify deficiencies, and ensure compliance. The ideal candidate will be proficient at abstracting appropriate diagnosis from supporting documentation in the medical record as well as assuring that performance measures are being properly reported. These ongoing audits will be performed in order to assure that submitted ICD-10-CM codes are fully supported by the clinical documentation and are being coded to the highest specificity. Auditor will participate in various special projects stemming from results of previous audits and report any improvement or nonengagement. Initial audits of new practices will be assigned in order to determine how providers can best be supported. Auditor will analyze findings of completed audits to determine coding error trends and make recommendations for process improvements to prevent their reoccurrence. Must have up to date knowledge of quality performance measures and risk adjustment methodology.

What's Expected:

Use critical thinking skills to determine any deficiencies in provider documentation, proper coding, and performance reporting. Ability to abstract codes from claims data, diagnostic testing, labs, specialist, and hospital notes. Assure that all ICD 10 codes assigned are coded to the highest specificity and are supported in the medical record.
Document clear, and accurate results based on current coding guidelines for any errors or omissions on audit spreadsheet, with particular focus on missed opportunities related to patient care. Record potential risk opportunities based on complete chart reviews, suspect reports, and open Gap reports.
Quantify and report data found according to established protocol.
Must be able to identify any potential areas of noncompliance to include fraud, abuse, incorrect coding according to government guidelines. Auditor will report findings to supervisor to investigate and implement corrective steps when necessary.
Perform quarterly Quality Assurance reviews on internal coders and outside vendors. Maintain logs of findings. All coding entities as well as members of audit team will be required to maintain an accuracy rating of 95% while meeting productivity requirements.
Monitor and report error trends to target educational opportunities. Able to communicate audit results with providers and coding team effectively.
Commit to conduct all audits according to established ethical standards and assure accurate coding in accordance with all regulatory requirements.

Requirements

Candidates must have a reliable and stable broadband internet connection with a minimum of 25 Mbps download and 3 Mbps upload speeds to ensure effective remote work and communication.
Education:
Bachelor's degree in a related field and/or the equivalent combination of training, education, and experience, required
Certifications:
Preferred Certified Professional Medical Auditor (CPMA), Certified Risk Adjustment Coder (CRC), Certified Professional Coder (CPC)
Years of Related Experience:
3 years HCC/Risk Adjustment experience
3 years Auditor experience

Skills:

Strong time management and organizational skills. Able to meet assigned deadlines
Knowledge of proper ICD-10-CM, CPT, and HCPCS coding guidelines and principles
Experienced with various EMR systems
Knowledge of medication classes, anatomy, physiology, disease interactions, medical terminology
Knowledge of industry and governmental regulations/guidelines to include individual payer rules of proper reporting.

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

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