Risk Adjustment Coding Auditor

MetroPlusHealth provides the highest quality healthcare services to residents of Bronx, Brooklyn, Manhattan, Queens and Staten Island through a comprehensive list of products, including, but not limited to, New York State Medicaid Managed Care, Medicare, Child Health Plus, Exchange, Partnership in Care, MetroPlusHealth Gold, Essential Plan, etc. As a wholly-owned subsidiary of NYC Health + Hospitals, the largest public health system in the United States, MetroPlusHealth's network includes over 27,000 primary care providers, specialists and participating clinics. For more than 30 years, MetroPlusHealth has been committed to building strong relationships with its members and providers.

Position Overview

The Risk Adjustment Coding Auditor works with Risk Adjustment leadership to design and implement programs, policies, and procedures that promote Risk Adjustment coding accuracy at MetroPlusHealth. This individual participates in hiring, training and managing a seasonal team of Risk Adjustment coders/auditors.

The Risk Adjustment Coding Auditor reviews Risk Adjustment vendor coding quality, performs Risk Adjustment Data Validation (RADV) audits, helps create policies and procedures to reduce regulatory audits risks, and is educator to internal and external staff about compliant coding. This individual also manages first-pass risk adjustment coding projects, including any of the following Risk Adjustment models: HHS-HCC, CMS-HCC and 3M CRG (New York State Medicaid).

• Works with Risk Adjustment leadership to design and carry out annual audits of Risk Adjustment vendors to ensure they comply with state and federal coding quality guidelines (i.e. Medicare, ACA and Medicaid coding standards).
• Coordinates the training and supervising of a team to carry out annual projects to retrieve provider medical records and document diagnosis codes using prevailing coding standards.
• Aids in creating Coding Policies and Procedures that ensure compliance with federal and state coding standards.
• Reviews policy documents from third parties to ensure they comply with MetroPlusHealth standards.
• Creates coding training documents and educational materials. Revises and updates those documents for ongoing Risk Adjustment coding education.
• Proactively reviews federal and/or state coding guidelines. Serves as internal Subject Matter Expert on coding regulations.
• Works with Risk Adjustment leadership to respond to federal and state coding audit requests, including RADV audits.Integral in achieving high coding compliance scores by reviewing audited medical records and filing discrepancy justification reports where appropriate.
• Helps design and implement Corrective Action Plans when coding deficiencies are identified to ensure high-quality data submissions to CMS and New York State.

• Bachelor's degree, preferably in health information administration (HIA) or health information technology (HIT); and four (4) years of experience in Risk Adjustment Coding/Auditing; or
• High school diploma or its educational equivalent, and post-secondary certification in a coding, allied health, or medical technical program, approved by a nationally accredited agency (e.g., CAHIIM, ACCSC); current CRC certification, and eight (8) years of experience in Risk AdjustmentCoding/Auditing.
• Strong understanding of at least 2 of the 3 the following Risk Adjustment models: HHS-HCC (Commercial), CMS-HCC (Medicare) and CRG (New York State Medicaid).
• Up-to-date knowledge of CMS regulations around RADV audits and Risk Adjustment coding.
• Ability to find and interpret regulatory guidance and integrate into internal policies and procedures to decrease regulatory risks.
• Experience auditing external coding vendors. This includes review of vendor work product, conducting coding audits, and compiling/summarizing audit results.
• Must be able to work independently to manage multiple concurrent coding initiatives and projects
• AAPC: CPC required, CRC preferred, CPMA desired.
• AHIMA: CCS and/or CCS-P preferred, RHIT and/or RHIA desired.

Professional Competencies

• Integrity and Trust
• Customer Focus
• Functional/Technical skills
• Writing/Oral Communication

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