Alignment Health is seeking a remote Risk Adjustment Compliance Auditor to support auditing and compliance activities related to risk adjustment data submitted to CMS. In this role, you will conduct provider and coder-level audits, review medical record documentation and coding accuracy, identify compliance risks and outliers, and support RADV and other risk adjustment audit initiatives.

This position is ideal for an experienced certified coder with a strong understanding of risk adjustment, HCC coding, compliance auditing, and CMS guidelines within a health plan, IPA, or managed care environment. You will partner closely with Risk Adjustment leadership and cross-functional teams to help ensure coding accuracy, regulatory compliance, audit readiness, and corrective action follow-through across the organization.

The role combines auditing, documentation review, reporting, compliance monitoring, and collaborative problem-solving in a fully remote environment. You will also help provide audit feedback and compliance education to internal and provider-facing stakeholders as needed.

Schedule:
- Full-time, Monday - Friday
- Initial training schedule will align primarily with Pacific Time business hours
- Flexible working hours available post-training based on business needs and team collaboration

Job Duties/Responsibilities:
1. Monitors coding prevalence reporting, internal reporting trends, and coding outliers to support compliance and audit readiness.
2. Reviews IPA Policies and procedures to ensure programs are compliant.
3. Monitors internal coding staff accuracy percentages to ensure they are tracked and maintained.
4. Monitors coding vendor's accuracy percentages to ensure the coding accuracy and quality of the data submitted to CMS.
5. Works with Risk Adjustment Management on data validation and RADV coding audit activities, including review of audit outcomes, findings, completeness, and coding accuracy of submissions to CMS.
6. Maintains and develops audit tracking, reporting, and management tools related to Risk Adjustment Compliance activities.
7. Ensures compliance with all applicable federal, state & and local regulations, as well as institutional/organizational standards, practices, policies & procedures.
8. Works with Risk Adjustment Management to monitor HCC corrective action plans and follow-up activities related to audit and review findings.
9. Suggests customizations of Risk Adjustment education for support staff, PCPs, specialists, employees, contracted employees and central departments.
10. Utilizes, protects, and discloses Alignment Healthcare patients' protected health information (PHI) only in accordance with Health Insurance Portability and Accountability Act (HIPAA) standards.
11. Maintains current knowledge of CMS audit processes, risk adjustment regulations, and industry best practices through ongoing education, professional development, and participation in relevant professional organizations.
12. Contributes to team effort by accomplishing related results as needed.
13. Represents and actively participates in RADV and other risk adjustment-related audits and compliance activities.
14. Other duties as assigned to meet the organization's needs.

Job Requirements:

Experience:
• Required: Minimum 3 years of professional coding experience in a medical group or health plan setting.
• Preferred: None.

Education:
• Required: Bachelor's degree in business administration, health care management or in a related field or 4 years additional experience in lieu of education.
• Preferred: None.

Training:
• Required: Certified Coder required - CPC, CCS & CCS-P.
• Preferred: Certified Auditor.

Specialized Skills:
• Required:

• Experience with strategic planning in risk mitigation.
• Previous use of Epic, Allscripts, EZCap a plus.
• Proficient user in MS office suite, MS access a plus.
• Ability to communicate positively, professionally and effectively with others; provide leadership, teach and collaborate with others.
• Effective written and oral communication skills; ability to establish and maintain a constructive relationship with diverse members, management, employees and vendors;
• Mathematical Skills: Ability to perform mathematical calculations and calculate simple statistics correctly
• Reasoning Skills: Ability to prioritize multiple tasks; advanced problem-solving; ability to use advanced reasoning to define problems, collect data, establish facts, draw valid conclusions, and design, implement and manage appropriate resolution.
• Problem-Solving Skills: Effective problem solving, organizational and time management skills and ability to work in a fast-paced environment.
• Report Analysis Skills: Comprehend and analyze statistical reports.

Licensure:
• Required: Certified Coder required - CPC, CCS & CCS-P.
• Preferred: None.

Essential Physical Functions:

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

1. While performing the duties of this job, the employee is regularly required to talk or hear. The employee regularly is required to stand, walk, sit, use hand to finger, handle or feel objects, tools, or controls; and reach with hands and arms.

2. The employee frequently lifts and/or moves up to 10 pounds. Specific vision abilities required by this job include close vision and the ability to adjust focus.
Pay Range: $64,384.00 - $96,577.00
Pay range may be based on a number of factors including market location, education, responsibilities, experience, etc.