We are an independent, Florida-focused organization with a long-standing commitment to delivering high-quality care to seniors and the communities we serve. Our work centers on improving health outcomes, enhancing the patient experience, and supporting value-based care models. As part of WellMed Optum Florida, team members collaborate across clinical and operational functions to support older adults with compassionate, coordinated care. We foster a culture of integrity, continuous improvement, and respect, offering opportunities for professional growth while making a meaningful impact. Our focus on seniors’ health drives innovation in care delivery, risk adjustment, and provider support across the Greater Tampa Bay Area and beyond.
LOCATION The Risk Adjustment Coding Auditor & Provider Educator is a full-time hybrid role based in the Greater Tampa Bay Area, with a mix of onsite visits and some work-from-home flexibility.
ABOUT THE ROLE The Coding Auditor / Educator is responsible for conducting coding and documentation audits to evaluate compliance with federal and state regulations, payer requirements, and organizational policies. As a member of the Legal & Compliance / Revenue Integrity Department, this individual contributor role supports the effectiveness of the organization’s compliance program by identifying coding risks, monitoring documentation accuracy, validating reimbursement integrity, and recommending corrective actions.
This role ensures accurate risk adjustment coding, HCC capture, and E/M documentation in a full-risk, value-based care environment. The position supports compliance with CMS-HCC risk adjustment guidelines, OIG audit expectations, and RADV preparedness. Working closely with providers, clinical leadership, revenue cycle, population health, and compliance teams, the Coding Auditor / Educator performs retrospective and prospective audits, analyzes coding trends, supports regulatory readiness, and delivers targeted education to providers and coding staff across WellMed Optum Florida's clinic network of approximately 1,600 employees and 94 clinic locations.
WHAT YOU'LL DO Coding Audit and Compliance Reviews Conduct professional coding audits for physician, advanced practice provider, and ancillary services to assess coding accuracy, documentation quality, and compliance with applicable regulations.
Perform retrospective, prospective, focused, and risk-based audits involving E/M services, risk adjustment coding, procedural coding, and diagnosis coding.
Evaluate medical record documentation to ensure compliance with CMS, Medicare Advantage, Medicaid, commercial payer, and organizational requirements.
Audit encounters for documentation sufficiency supporting reported diagnoses, with emphasis on risk adjustment data validation (RADV) standards.
Conduct focused audits in response to compliance concerns, OIG work plan priorities, or payor-initiated reviews.
Monitor for potential upcoding, unbundling, and unsupported diagnoses, and recommend corrective actions.
Risk Adjustment and Documentation Integrity Audit Hierarchical Condition Category (HCC) coding and supporting documentation for accuracy and completeness.
Validate chronic condition capture and coding practices within value-based care programs.
Identify documentation gaps, coding trends, and potential compliance risks impacting quality, reimbursement, and regulatory compliance.
Support annual risk adjustment coding accuracy assessments, chart review programs, and documentation improvement initiatives.
Compliance Monitoring and Reporting Prepare detailed audit reports, findings summaries, and corrective action recommendations for providers, operational leaders, and compliance leadership.
Monitor audit outcomes and track corrective action plans to ensure timely resolution of identified deficiencies.
Provide coding audit metrics and trend analyses to support compliance reporting, governance activities, and organizational risk monitoring.
Provider Education and Collaboration Develop and deliver provider and staff education on accurate coding and documentation practices, including HCC coding, E/M guidelines, CMS-specific requirements, regulatory changes, and audit findings.
Create training materials, tip sheets, and reference guides tailored to value-based care documentation needs.
Conduct one-on-one and group training sessions, including new provider orientation on coding and documentation expectations.
Serve as a subject matter resource on coding compliance and documentation requirements.
Regulatory and Audit Support Assist with internal audits, external audits, payer reviews, and regulatory examinations related to coding, billing, and documentation practices.
Support responses to coding-related inquiries from regulatory agencies, health plans, and government entities.
Participate in compliance risk assessments and special investigations involving coding and billing concerns, including potential fraud, waste, and abuse matters.
WHAT YOU'LL BRING Required Qualifications Associate’s or Bachelor’s degree in Health Information Management, Healthcare Administration, Nursing, Business, or a related field, or an equivalent combination of education and experience.
Minimum of 3+ years of medical coding experience, with at least 2 years in a coding audit or educator role within a physician practice, managed care organization, health system, or comparable healthcare setting.
Current coding certification required: CPC, CCS, CRC, or equivalent.
Demonstrated expertise in risk adjustment and HCC coding within a Medicare Advantage or value-based care setting.
Strong knowledge of ICD-10-CM, CPT, HCPCS, CMS-HCC risk adjustment methodology, and E/M documentation guidelines.
Experience with RADV audit preparation and chart review processes.
Familiarity with CMS regulations, OIG compliance guidance, and fraud, waste, and abuse (FWA) requirements.
Proficiency with electronic health records, coding software, and Microsoft Office applications.
Excellent analytical, problem-solving, written, verbal, presentation, and interpersonal skills, with the ability to educate providers at all levels.
Ability to travel to clinic sites across Florida as needed.
Preferred Qualifications Certified Professional Medical Auditor (CPMA) certification (strongly preferred).
Experience in value-based care, Medicare Advantage, accountable care organizations, or physician practice management.
Experience supporting compliance programs, regulatory audits, and investigations.
Experience with healthcare analytics, reporting tools, and coding analytics platforms.
Familiarity with population health programs and quality measurement initiatives within managed care environments.
Wellmed Optum Florida is an equal opportunity employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, age, disability, veteran status, genetic information, or any other characteristic protected by applicable federal, state, or local law.
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