Quality Coding Auditor

About the role:

To be fully engaged in providing Superior Quality, Memorable Client and Vendor Experiences by effectively monitoring overall Risk Adjustment.  The individual will provide superior quality by performing audits pertaining to risk adjustment coding efforts.  The individual will be responsible for daily operations pertaining to auditing functions as assigned.    The individual will provide superior customer experience by educating internally and externally on opportunities for improvement discovered during auditing.  This individual will work closely with Management to implement benchmarks, establish acceptable thresholds, and effective quality assurance programs.

Who You Are:

• Maintain a quality assurance program: Ensure that the QA program is continuously refined to meet organizational and client standards for accuracy and compliance in risk adjustment coding.
• Play a key role in ensuring coding compliance and accuracy: Ensure adherence to regulatory requirements (CMS, OIG, ICD-10-CM Coding Guidelines, RADV) and internal standards for external vendors, contributing to the overall accuracy of coding.
• Monitor the performance of Risk Adjustment Operations: Track and assess the performance of external coding vendors, identifying areas for improvement in workflows, compliance, and coding accuracy.
• Provide expertise as it relates to coding compliance for new and existing services: Serve as a subject matter expert (SME) to product and engineering teams to enhance coding workflows, improve user experience in new products, and ensure coding compliance with organizational, federal, state, and third-party requirements.
• Data analysis for coding workflows and learning needs: Conduct data analysis to track and trend coder performance, identifying learning needs and areas for guideline clarification or updates. Use these insights to inform educational efforts and product improvements.
• Assist in effective communication of information: Collaborate on developing and delivering presentations, reports, educational programs, and memoranda to communicate audit results and guidelines. Provide formal and informal education to coding vendors, and staff.
• Report findings to Leadership in a timely and effective manner: Present audit results, data trends, and process improvements to leadership consistently, ensuring that necessary changes are implemented to maintain compliance and accuracy.
• Support audit processes and identify process improvements: Ensure that audit workflows are properly documented and that audit results are maintained in an organized manner. Continuously identify and implement process improvements to enhance audit and coding accuracy.
• Assist in developing an effective training program: Contribute to the creation of training programs focused on correct coding techniques and best practices, ensuring staff and vendors stay updated on new guidelines and compliance requirements.
• Assist with training new auditors and staff: Support the training of new auditors and other staff members to maintain a high level of expertise and ensure continuity in coding compliance and auditing processes.
• SME support for product enhancements: Act as an SME in cross-functional collaborations with product and engineering teams, contributing to the design of coding workflows and user experience enhancements in new and existing products.
• Create methods to share program and quality updates: Develop ways to share information about the quality assurance program, audit outcomes, and key initiatives with Apixio Management on a regular cadence (monthly or as needed).
• Perform other duties as assigned: Take on additional responsibilities as necessary to ensure the continuous improvement and compliance of coding and auditing operations.

What you bring to the table:

• Bachelor’s degree in a relevant field of study preferred, or 9 years of related work experience as a coder, with a minimum of 7 years of coding experience in risk adjustment for both ACA and MA; CRC, CPC, or CCS certification preferred.

• Expert knowledge of both Medicare Advantage and Commercial Risk Adjustment. 

• Research and problem resolution skills.

• Must possess strong managerial, financial, and analytical skills.
• Consistent demonstration of commitment to quality, customer focus, productivity, and process improvement.
• Strong communication skills to effectively interact all levels of the organization, business unit leaders, and staff in a tactful and positive manner.
• Experience overseeing remote (Work at Home) operations.
• Exceptional interpersonal skills, proven success in complex and ambiguous environments.
• Ability to work independently, with high productivity, and regularly meet deadlines.
• Demonstrates excellent written and verbal communication skills conforming to all rules of punctuation, grammar, diction and professional style.
• Experience in initiating, developing and monitoring policies, internal control procedures and operating standards.