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Risk Adjustment Auditor Job in Ann Arbor, Michigan

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Job Title: Risk Adjustment Auditor

Skills:CPC,Coding,RHIT,Risk Adjustment,Abstraction,Medical Records,Compliance,ICD-10
Required Certifications:Certified Risk Adjustment Coder
Preferred Certifications:CPC or RHIT
Required Experience:1 to 2 years
Location:Ann Arbor, MI
Date Posted:7/31/2018


Performs medical record audits to ensure accurate assessment of external or internal ICD-10-CM code selection and appropriate documentation to support.  The objective is to improve specificity and accuracy of diagnoses coding to show the true clinical condition of patients.




1.      Perform code abstraction and/or coding quality audits of medical records to ensure ICD-10-CM codes are accurately assigned and supported by clinical documentation.

2.      Retrieves and/or performs electronic medical chart reviews.

3.      Review and assign accurate medical codes for diagnoses performed by physicians and other qualified healthcare providers in the office or facility setting (e.g., inpatient hospital).

4.      Verifies accuracy, completeness, and appropriateness of diagnosis codes based on basic to moderately complex medical documentation provided.

5.      Identify and communicate documentation deficiencies to providers to improve documentation for accurate risk adjustment coding.

6.      Uses data analysis and language software to identify opportunities and review for acceptance or rejection to modify a claim based on documentation and ICD 10-CM correct coding conventions. 

7.      Identifies and documents coding observations or discrepancies and provides information to management team to further enhance quality and/or provider education.

8.      Performs medical record audits on external vendors risk adjustment work to ensure compliance with CMS and ICD 10 coding conventions.

9.      Select correct ICD code assignment by proficient analysis and translation of diagnostic statements, physicians' orders, and other pertinent documentation.

10.   Critically evaluate valid encounters, including face-to-face, legibility and valid signature, per Medicare, Commercial and Federal and State requirements.

11.   Assist coding leadership by making recommendations for process improvements to further enhance coding quality goals and outcomes.

12.   Understand the anatomy, pathophysiology, and medical terminology necessary to correctly code Facilitate and obtain appropriate physician documentation for any clinical conditions or procedures to support the appropriate severity of illness diagnoses.

13.   Performs other duties as assigned.




1.      Creates a positive, professional, service-oriented work environment by supporting the IHA CARES mission and core values statement.

2.      Must be able to work effectively as a member of the Compliance team.

3.      Successfully completes IHA's "The Customer" training and adheres to IHA's standard of promptly providing a high level of service and respect to internal or external customers.

4.      Maintains knowledge of and complies with IHA standards, policies and procedures, including IHA's Employee Handbook.

5.      Maintains general knowledge of IHA office services and in the use of all relevant office equipment, computer, and manual systems.

6.      Serves as a role model, by demonstrating exceptional ability and willingness to take on new and additional responsibilities.  Embraces new ideas and respect cultural differences.

7.      Uses resources efficiently.




Performance that meets or exceeds IHA CARES Values expectation as outlined in IHA Performance Review document, relative to position.




EDUCATION:  Bachelor's Degree or equivalent combination of education and experience.

CREDENTIALS/LICENSURE: Certified Professional Coder or RHIT certification is required; Certified Risk Adjustment Coder (CRCtm) certification is required.

MINIMUM EXPERIENCE:  At least 2 years' experience required abstracting risk adjusted codes from acceptable medical record documentation in either a hospital or physician setting.




1.      Maintain current knowledge of ICD-10-CM codes, CMS documentation requirements, and state and federal regulations.

2.      Maintains working knowledge of federal, state, and insurance company regulations and contract requirements affecting compliance in a healthcare setting; compliance plan and auditing standards.

3.      Substantial knowledge of managed care and insurance practices, insurance claims and billing process, fee schedules and pricing.

4.      Thoroughly comprehend medical coding guidelines and regulations including compliance and reimbursement and the impact of diagnosis coding on risk adjustment payment models.

5.      Maintains currency in all coding and reimbursement methods researching literature and attends professional seminars, workshops, and conferences as required by the AHIMA and/or AAPC to maintain professional certification.

6.      Maintain and grow the current knowledge of the Medicare and Commercial Risk Adjustment outpatient/inpatient billing systems/processes.

7.      Stay current on all changes in coding conventions and coding updates.

8.      Adhere to the coding guidelines.

9.      Work both in a team and individual environment and is confident working with a wide variety of healthcare professionals.

10.   Ability to meet productivity and accuracy standards

11.   Ability to defend coding decisions to both internal and external audits.

12.   Demonstrated understanding and/or hands-on experience with office processes, procedures and workflows.

13.   Proficiency in multi-tasking and meeting sensitive deadlines in a fast-paced environment with a personal commitment to producing the highest quality work and providing extraordinary customer service; demonstrated ability to effectively follow through on assigned projects.

14.   Proficient in operating a standard desktop and Windows-based computer system, including but not limited to, Microsoft Word and Excel, intranet and computer navigation.  Ability to use other software as required while performing the essential functions of the job including EPM and EHR systems.

15.   Excellent communication skills in both written and verbal forms, including proper phone etiquette.

16.   Ability to work collaboratively in a team-oriented environment; courteous, professional and friendly demeanor.

17.   Ability to work effectively with various levels of organizational members.

18.   Good organizational and time management skills to effectively juggle multiple priorities and time constraints in a fast-paced environment.

19.   Ability to exercise sound judgment and problem-solving skills.

20.   Ability to maintain any organizational information in a confidential manner.

21.   Successful completion of IHA competency-based program within introductory and training period.

22.   Ability to work overtime hours as scheduled.

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