Sr. Medical Quality Auditor Risk Adjustment

The Senior Risk Adjustment Quality Auditor utilizes their expertise and industry standard coding guidelines in performing quality accuracy audits for both internal Companies Coders and external Vendors, Partners, and Provider Groups, ensuring the accuracy of ICD-10 coding and claims data for CMS/HHS risk adjustment data submissions. The Senior Risk Adjustment Quality Auditor shall assist Leadership with the quality audit processes, identify trends and opportunities for training and education. This position shall utilize critical thinking skills and effective communication to ensure coding compliance and oversight of same.

Important to Know

• Candidates that move forward in the process may be asked to complete an assessment that simulates the responsibilities of this role

• CRC (Certified Risk Adjustment Coder from AAPC) is required

• One of the following certifications is required in addition to the CRC certification

  • CPC (Certified Professional Code from AAPC)

  • COC (Certified Outpatient Coder from AAPC)

  • CIC (Certified Inpatient Coder from AAPC)

  • CCS (Certified Coding Specialist from AHIMA)

  • CCS-P (Certified Coding Specialists Physician Based from AHIMA)

What You Will Be Doing

Internal Audit Accountabilities

• Execute audit procedures as outlined by Leadership including perform and document findings of quality accuracy reviews/quality audits of coding and documentation completed by Companies Internal Risk Adjustment Coders/Auditors to ensure consistency and accuracy of ICD-10 coding and industry standards.

• Advise Companies Internal Coders/Auditors on proper code selection, documentation guidelines as well as assist with training and education.

• Research and communicate ICD-10, Coding Clinics, and other industry standard guidance, when appropriate, for facilitating quality review findings and education.

External Audit Accountabilities

• Perform and document findings of quality accuracy reviews/quality audits of coding and documentation completed by External Vendors, Partners and/or Provider Groups to ensure consistency and accuracy of ICD-10 coding.

• Research and communicate ICD-10, Coding Clinics, and other industry standard guidance, when appropriate, for facilitating quality accuracy reviews/quality audits findings.

• Communicate with external Vendors, Partners and/or Provider Groups to share out audit results and educational materials.

Senior Audit Accountabilities

• Escalates trends in quality accuracy reviews/quality audits findings to Leadership and provide suggested corrective actions

• Assists Leadership and resources to support audit scope, deadlines, and objectives.

• Assist Leadership with improvements to the quality accuracy reviews/quality audits process, identifying risks, evaluating controls, and preparing documentation.

• Assists in developing, maintaining, and updating departmental procedures, workflows, and other work tools/job aides. (30%)

What We Require

• 4+ years related work experience or equivalent combination of transferable experience in Risk Adjustment Coding, Auditing, Coding Accuracy experience and/or Provider Education

• Related Bachelor’s degree or additional related equivalent work experience or equivalent work experience

• Demonstrated knowledge of CMS and HHS Risk Adjustment Programs Experience resolving escalated issues and barriers. Excellent communication and collaboration skills both with internal and external audiences Knowledge of health plan operations Knowledge of provider operations

• CRC (Certified Risk Adjustment Coder from AAPC) Upon Hire

• At least one of the following upon hire:

  • CPC (Certified Professional Code from AAPC)

  • COC (Certified Outpatient Coder from AAPC)

  • CIC (Certified Inpatient Coder from AAPC)

  • CCS (Certified Coding Specialist from AHIMA)

  • CCS-P (Certified Coding Specialists Physician Based from AHIMA)

What We Prefer

• Bachelor’s degree Bachelor’s degree in any subject matter or equivalent work experience

• Experience using Full ICD-10 CM code capture

• CPMA (Certified Professional Medical Auditor from AAPC) Upon Hire

• Demonstrated Florida Blue knowledge

• Demonstrated understanding of CMS compliance standards

General Physical Demands Sedentary work: Exerting up to 10 pounds of force occasionally to move objects. Jobs are sedentary if traversing activities are required only occasionally. What We Offer

As a Florida Blue employee, you will thrive in our Be Well, Work Well, GuideWell culture where being well as an individual, and working well as a team, are both important in serving our members and communities. To support your wellbeing, comprehensive benefits are offered. As an employee, you will have access to:

• Medical, dental, vision, life and global travel health insurance
• Income protection benefits: life insurance, short- and long-term disability programs
• Leave programs to support personal circumstances
• Retirement Savings Plan including employer match
• Paid time off, volunteer time off, 10 holidays and 2 well-being days
• Additional voluntary benefits available; and a comprehensive wellness program

Employee benefits are designed to align with federal and state employment laws. Benefits may vary based on the state in which work is performed. Benefits for intern, part-time and seasonal employees may differ. To support your financial wellbeing, we offer competitive pay as well as opportunities for incentive or commission compensation. We also conduct regular annual reviews with pay for performance considerations for base pay increases.

Annualized Offer/Hiring Range: $71,200 - $89,000 Annualized Salary Range: $71,200 - $115,700 Final pay will be determined with consideration of market competitiveness, internal equity, and the job-related knowledge, skills, training, and experience you bring. We are an Equal Employment Opportunity employer committed to cultivating a work experience where everyone feels like they belong and can perform at their best in pursuit of our mission. All qualified applicants will receive consideration for employment.