Risk Adjustment Auditor

Department: HS-RAPS
Reports to: Supv, Risk Adjustment Audit & Provider Education
Location: Tampa, FL

Performs quality assurance of ICD-10 auditing of WellCare's Medical Coding Specialists and external vendors that submit risk adjustment data based on medical record reviews. Subject Matter Expert (SME) in the Risk Adjustment Data Validation (RADV) auditing process, all internal and/or external audits for both Medicare and Medicaid.

Essential Functions:

  • Performs quality assurance auditing (i.e. ensure appropriateness and accuracy of ICD-10 coding) for WellCare’s Medical Coding Specialists;
  • Accountable for communicating QA results to the Medical Coding Specialists with suggestions for improvement and re-training topics;
  • Responsible for auditing external vendors’ coding based on medical record reviews;
  • Responsible for conducting all activities in relation to CMS RADV audits: medical record review, identifying best medical record, submitting all necessary paperwork, transmitting data to CMS, responding to all inquiries, and providing expertise and support during the appeals process;
  • Works on additional risk adjustment audit requests (i.e. outside auditors’ requests).
  • Serves on the RADV Committee as subject matter experts.
  • Perform other duties as necessary.
Additional Responsibilities:
    Candidate Education:
    • Required A High School or GED
    • Preferred A Bachelor's Degree in a health related field or finance
    • Preferred Other Bachelor's degree may substitute for 4 years of the 5 years required experience
    Candidate Experience:
    • Required 5 years of experience in professional coding either in a hospital or physician setting
    • Required 3 years of experience in coding with knowledge of RAPS
    Candidate Skills:
    • Intermediate Demonstrated interpersonal/verbal communication skills
    • Intermediate Demonstrated written communication skills
    • Intermediate Demonstrated organizational skills
    • Intermediate Ability to work as part of a team
    • Intermediate Ability to work independently
    Licenses and Certifications:
    A license in one of the following is required:
    • Required Certified Professional Coder (CPC)
    • Preferred Certified Professional Medical Auditor (CPMA)
    • Preferred Other Certified Risk Adjustment Auditor (CRC)
    Technical Skills:
    • Required Intermediate Microsoft Outlook
    • Required Intermediate Microsoft Excel
    • Required Intermediate Microsoft Word
    • Required Intermediate Microsoft PowerPoint
    • Required Intermediate Other Knowledge of RAPS and HEDIS

      About us
      Headquartered in Tampa, Fla., WellCare Health Plans, Inc. (NYSE: WCG) focuses exclusively on providing government-sponsored managed care services through Medicaid, Medicare Advantage and Medicare Prescription Drug Plans to families, children, seniors and individuals with complex medical needs. WellCare is a Fortune 500 company, and in 2018, was recognized as a Fortune "World's Most Admired Company", ranking in the top five among the health insurance and managed care industry-a testament to the hard work and dedication of the company's nearly 9,000 associates who each day live WellCare's values and deliver on its mission to help its members live better, healthier lives. The company serves approximately 4.4 million members nationwide as of Dec. 31, 2017. For more information about WellCare, please visit the company's website at www.wellcare.com. EOE: All qualified applicants shall receive consideration for employment without regard to race, color, religion, creed, age, sex, pregnancy, veteran status, marital status, sexual orientation, gender identity or expression, national origin, ancestry, disability, genetic information, childbirth or related medical condition or other legally protected basis protected by applicable federal or state law except where a bona fide occupational qualification applies. Comprehensive Health Management, Inc. is an equal opportunity employer, M/F/D/V/SO.