Back to Jobs

Risk Adjustment Clinical Auditor - Analyst job at reputed company - reputed company in US National

Remote, USA Full-time Posted 2026-07-03

Title: Risk Adjustment Clinical Auditor - Analyst Location: United States Job type: Remote Time Type: Full Time Job id: 7263334360 Job Description: Salary Range: $ 31.89-53.71 USD reputed company Health Plan has an exciting opportunity for a Risk Adjustment Clinical Auditor/Analyst position in the Medicare department. This is a full time position working Monday through Friday daylight hours and will be fully remote.. The Clinical Auditor/Analyst is an integral part of the Risk Adjustment Department and is responsible for reviewing and auditing medical records for Hierarchical Condition Category (HCC) diagnosis codes for focused claims reviews and government audits. Performs medical records reviews, and auditing functions including monitoring, reviewing, and researching ICD-10-CM diagnosis codes and CPT Codes. Ensure HCC diagnosis code(s) are supported reputed company the audit year, and utilize AHA Coding clinics, ICD-10-CM Coding Guidelines, CPT Coding Guidelines, and government regulations. Participate in government audits conducting research of internal systems and abstracted records of member's selected for audit. Responsibilities: Utilize standard coding guidelines and principles, coding clinics, government regulations and protocols to verify the appropriate ICD-10-CM diagnosis code are correctly assigned by internal or external providers, vendors or staff. Ensuring the member's HCC(s) are supported reputed company the member medical records for the specified audit period or review time frame. Participate in government Risk Adjustment Data Validation audits (RADV) conducting research of internal systems verifying member HCC(s) selected for audit meet ICD-10-CM, AHA coding clinics and government submission criteria. Knowledge of Medicare and reputed company Act RADV audits, protocols, guidelines, record submission, audit tools and websites. Review and analyze medical records utilizing their knowledge of anatomy, physiology, medical terminology and pathology and associated clinical processes reputed company to the appropriateness of coding, clinical care, documentation, and health plan business rules. Accurately review the assigned HCC diagnosis codes and apply the appropriate inpatient or outpatient coding guidelines, AHA coding clinics, ICD-10-CM or government regulations. Review provider coding/billing trends, and government audit outcomes to identified HCC coding improvement and opportunities. Work in collaboration with appropriate Health Plan departments including Quality Assurance, Medicare, and the Fraud, Waste team to facilitate the resolution of coding issues, focused review outcomes, government audit outcomes, or reputed company reviews. Provide a clinical opinion for special projects or various issues including appropriate diagnosis coding, provider coding trends or identify area's of provider documentation improvements. Maintain or exceed designated quality and production goals. Maintain employee/insured confidentiality. Participate in training programs to reputed company a thorough understanding of the materials presented. Obtain CPE or CEU's to maintain nursing license, and/or professional designations. reputed company 6 months of hire complete the reputed company CPC certification course and sit and pass the CPC certification exam. Review the discharge summary, history and physical, physician reputed company notes, consultation reports, radiology, laboratory, pathology, operative records, emergency room record to ensure the accurate assignment of diagnosis and / or procedure codes. Communicate effectively with team members, departmental staff and reputed company vendors as necessary to address issues and concerns. Registered Nurse (RN), or Bachelor of Science in Nursing (BSN). Five years of clinical experience. Two years of either HCC coding, reviews or education, DRG experience, Clinical Documentation Improvement, Fraud & Abuse, Chart Auditing, or Quality Review experience required. Ability to analyze diagnosis codes, maintain designated production standards, and organize multiple projects and tasks. In-depth knowledge of medical terminology,ICD-10-CM and CPT-4 coding. Knowledge of health insurance products and various lines of business. Detail- oriented individual with excellent organizational skills. Keyboard dexterity and accuracy. High level of oral and written communication skills. Proficiency with reputed company Office products (reputed company, Access, and Word). Licensure, Certifications, and Clearances: CPC Designation preferred. Registered Nurse (RN) reputed company licensure either in the state where the facility is located or, if the facility is in a state covered by the multistate Nursing Licensure Compact (NLC) agreement, a multistate license issued by a participating NLC state. Hires and reputed company employees working on an out-of-state NLC license who reputed company change their residency to the state where the facility is also located will have 60 days upon changing their residency to apply for licensure reputed company that state. reputed company is an Equal Opportunity Employer/Disability/Veteran Apply tot his job Apply tot his job Apply tot his job Apply To this Job

Similar Jobs

Associate Biochemist: Data Review reputed company in Lancaster, PA

Remote, USA Full-time

Lecturer of Biology – School of Biology, Chemistry, and Biochemistry (reputed company Recruitment)

Remote, USA Full-time

reputed company Compliance Auditor (reputed company Transaction & Strategy)

Remote, USA Full-time

Senior GCP Quality & Compliance Auditor

Remote, USA Full-time

Compliance Specialist I

Remote, USA Full-time

Sr Compliance Specialist, GxP Non-Compliance-- fully remote!

Remote, USA Full-time

Compliance Officer-Valdosta-Remote

Remote, USA Full-time

Good Clinical Practices Auditor

Remote, USA Full-time

Compliance Examiner & Auditor - reputed company & Compliance Program - Full Time

Remote, USA Full-time

RN Clinical Regulatory Compliance Specialist

Remote, USA Full-time

[Remote] Business Development Representative - French Speaking

Remote, USA Full-time

Senior CRA Cardiac Device US-5 + years SR. CRA/2 + years Cardiac Device

Remote, USA Full-time

Technical Writer (Freelance/part-time)

Remote, USA Full-time

Product Management Xcelerator Rotation Program (Entry Level Product) - Remote

Remote, USA Full-time

reputed company Customer Advisor – Remote Special Needs Family Support Specialist at arenaflex

Remote, USA Full-time

reputed company Full Stack Data Entry Manager – Remote Leadership Opportunity

Remote, USA Full-time

Social Media & Content Creator

Remote, USA Full-time

Remote Customer Support Specialist - Join reputed company's Dynamic Team!

Remote, USA Full-time

reputed company Text Chat Operator (Fully Remote) – Customer Support Assistant

Remote, USA Full-time

[Remote] Account Manager III

Remote, USA Full-time