Risk Adjustment Auditor and Physician Educator (4088)

JOB DESCRIPTION

The position description is a guide to the critical duties and essential functions of the job, not an all-inclusive list of responsibilities, qualifications, physical demands, and work environment conditions. Position descriptions are reviewed and revised to meet the changing needs of the organization.

TITLE: Risk Adjustment Auditor and Physician Educator

JOB OVERVIEW: The Risk Adjustment Auditor and Physician Educator is responsible for developing the process and reporting for performing annual, period, and other quality assurance reviews of medical record documentation and coding to ensure appropriate capture of Hierarchical Condition Categories (HCC) conditions. This position utilizes expertise and national coding guidelines as reference in performing medical record coding audits and in partnership with the Physician Champion, develops strategies for provider education and training.

DEPARTMENT: Health Information Management

WORK HOURS: Monday - Friday, typically 8:00 AM - 4:30 PM. Flexibility may be required to meet department and organization needs.

REPORTS TO: Director HIM and Revenue Integrity

PREREQUISITES:

• Bachelor's degree in health sciences, health management or related field or equivalent related health experience required.
• Minimum 3 years of experience in risk adjustment coding and medical record review.
• Minimum 3 years of experience delivering education and training to Physicians required.
• Certified Professional Coder (CPC) or Certified Coding Specialist-Physician Based (CCS-P) certification required.
• Certified Risk Adjustment Coder (CRC) required.
• Certified Professional Medical Auditor (CPMA) strongly preferred.
• Proficient in various computer applications, including Microsoft Office, Excel, Word, PowerPoint, Visio, and Outlook.

QUALIFICATIONS:

• In depth clinical understanding of chronic disease management.
• Demonstrated proficiency in Medicare Risk Adjustment methodologies and ICD-10 coding concepts.
• Experience in health systems operations including knowledge of value-based methodologies, payer reimbursement and coding conventions.
• Demonstrated continuous learning in clinical medicine; practical understanding of ICD-10-CM/PCS and ability to educate physicians on the merits of best practice documentation strategies.
• Demonstrated ability to interpret national documentation and coding guidelines and translation to effective auditing practices and tools.
• Demonstrated ability to identify issues in documentation and coding practices and develop plan to remediate.
• Demonstrated ability to meet deadlines, with good time management and prioritization skills.
• Self-motivated and able to work independently.
• Demonstrated ability for critical thinking skills, with focus on assessment, evaluation, and teaching.
• Strong organization and analytical thinking skills; detail oriented.
• Strong verbal, written and presentation skills.

UNIQUE PHYSICAL/MENTAL DEMANDS, ENVIRONMENT AND WORKING CONDITIONS

• Must possess ability to work independently, with a minimum of direction, and take initiative in problem solving.
• Must be able to interact professionally and effectively with a wide variety of people, including operations staff, providers, the general public, and departments in Valley Medical Center (VMC).
• Requires typing, legible handwriting and computer/keyboard skills.
• Regular and punctual attendance is a condition of employment.
• Requires the ability to maintain self-composure and a positive attitude under stress.
• Requires problem solving and coaching ability and effective resolution of conflicts.
• Must be able to function effectively in an environment with frequent interruptions and multiple tasks.

PERFORMANCE RESPONSIBILITIES:

Generic Job Functions: See Generic Job Description for Administrative Partner.

Essential Responsibilities and Competencies:

• Conduct medical record audits and quality assurance reviews related to Hierarchical Condition Categories (HCC) condition coding.
• In collaboration with the Physician Champion, develop and deliver education and training on HCC coding guidelines and policies.
• In collaboration with the Physician Champion and Medical Directors, assist in developing strategies to improve overall coding accuracy and compliance.
• Provide ongoing feedback to physicians regarding HCC coding guidelines and requirements.
• Facilitate educational in-services for physicians and other providers related to HCC coding and documentation compliance.
• Create and analyze reports related to trending and ongoing monitoring for coding improvement.
• Monitor coding prevalence reporting for coding outliers.
• Monitor responsiveness of physician queries and education engagement with focus on continuous improvement, providing outcome feedback and opportunities to physician leadership.
• Identify any barriers to completion of documentation goals with appropriate interventions.
• Engage with provider specialties to identify clinical documentation improvement initiatives, effectively tailoring adult learning and educational opportunities to each specialty.
• Review medical record documentation & update workflows that support the clinical picture, severity of illness and complexity of patient care.
• Track and trend audited projects and their outcomes to assure the highest level of coding accuracy is maintained.
• Develop risk adjustment training tools and education platform for new providers.
• Develop robust risk adjustment audit schedule for both new and existing providers.
• Attend all relevant ICD-10-CM/PCS and other billing/coding related educational offerings by CMS contractor effectively sharing with providers on a need-to-know basis integrating key concepts and elements as they relate to clinical documentation improvement into daily routines and practices of CDI.
• Utilize available encoder, grouper software and other coding resources to determine appropriate ICD-10-CM diagnosis codes mapped to HCC's.
• Appropriately translate national documentation and coding guidelines into effective auditing practices.
• Maintain professional and technical knowledge by attending educational workshops, reviewing professional publications, staying current of industry coding, compliance and HCC models.
• Maintain confidentiality of all protected health information.
• Follow the Mission, Vision, and Values of Valley Medical Center. Performs all job functions in a manner consistent with Valley's cultural expectations defined as Valley Values. These characteristics include quality performance, demonstrating compassion, respect, teamwork, community-centered awareness, and innovation.
• Complete additional projects and duties assigned.

Created: 2/2026 Grade: NC-10 FLSA: E Cost Center(s): 8490

Job Qualifications:

QUALIFICATIONS:

• In depth clinical understanding of chronic disease management.
• Demonstrated proficiency in Medicare Risk Adjustment methodologies and ICD-10 coding concepts.
• Experience in health systems operations including knowledge of value-based methodologies, payer reimbursement and coding conventions.
• Demonstrated continuous learning in clinical medicine; practical understanding of ICD-10-CM/PCS and ability to educate physicians on the merits of best practice documentation strategies.
• Demonstrated ability to interpret national documentation and coding guidelines and translation to effective auditing practices and tools.
• Demonstrated ability to identify issues in documentation and coding practices and develop plan to remediate.
• Demonstrated ability to meet deadlines, with good time management and prioritization skills.
• Self-motivated and able to work independently.
• Demonstrated ability for critical thinking skills, with focus on assessment, evaluation, and teaching.
• Strong organization and analytical thinking skills; detail oriented.
• Strong verbal, written and presentation skills.