CommUnityCare

Job Summary The Risk Adjustment Auditor is responsible for reviewing medical records and related documentation to ensure accurate capture of diagnoses in compliance with CMS risk adjustment guidelines and ICD-10-CM coding standards. This role plays a critical part in supporting accurate risk score calculation, regulatory compliance, and overall program integrity. Key Responsibilities Perform bi-directional retrospective and prospective medical record reviews to validate, clarify, and accurately capture risk adjusted diagnoses (HCCs) in accordance with CMS guidelines and MEAT documentation requirements. Ensure documentation supports coded conditions in accordance with ICD-10-CM, CMS, and payer-specific guidelines. Identify unsupported diagnoses, over coding, under-coding, and documentation gaps. Provide detailed audit findings and recommendations to coding teams, providers, and leadership. Monitor compliance with CMS Risk Adjustment Data Validation (RADV) standards. Track and...

Location: Tulsa, Oklahoma, United StatesCompany: CommUnityCarePosted: Job ID: 6283Req ID: 1133Location: Tulsa, OK, USAPosted: Job Family: CommercialPay Type: SalaryJOB SUMMARY:The Risk Adjustment Auditor is responsible for reviewing medical records and related documentation to ensure accurate capture of diagnoses in compliance with CMS risk adjustment guidelines and ICD-10-CM coding standards. This role plays a critical part in supporting accurate risk score calculation, regulatory compliance, and overall program integrity.KEY RESPONSIBILITIES:• Perform bi-directional retrospective and prospective medical record reviews to validate, clarify, and accurately capture risk adjusted diagnoses (HCCs) in accordance with CMS guidelines and MEAT documentation requirements.• Ensure documentation supports coded conditions in accordance with ICD-10-CM, CMS, and payer-specific guidelines.• Identify unsupported diagnoses, over coding, under-coding, and documentation gaps.• Provide detailed audit...

Job TitleResponsible for supervising and coordinating daily workflow and leadership of staff. Activities include developing operating procedures and managing personnel and resources.Key ResponsibilitiesServes as a resource to the department staff by providing technical direction and resolving workflow problems or improvement opportunities within the department.Assesses individual workload and staffing patterns. Selects, assigns, and evaluates personnel, and recommends or initiates associated personnel actions. Takes caseload as needed to assist with staffing needs. Ensure authorization timeframes and regulatory requirements are met.Interviews, hires, trains, and reviews all eligibility personnel in addition to problem-solving and disciplinary actions. Participates in analysis of current policies and procedures and in the development of new or updated standard operating procedures and workflows.Attends departmental, interdepartmental, and facility meetings as needed.Performs other...