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Risk Adjustment Auditor
Posted on 6/6/2022
United States
Experience Level
Desired Skills
  • Bachelor's degree in relevant field of study preferred or 3+ years related work experience
  • Certified Professional Coder with 2+ years of coding experience and at least 1 year of auditing experience
  • Expert knowledge of Risk Adjustment and HEDIS
  • Maintain a quality assurance program for data collected by the Risk Adjustment and HEDIS Departments
  • Help monitor the performance of the Risk Adjustment and HEDIS Teams and report findings to Senior Leadership, ensuring that appropriate changes are implemented
  • Support audit processes ensuring work flows and results are documented and maintained. Identify process improvements
  • Maintain confidentiality regarding individual error results
  • Help develop a training program regarding correct coding techniques and data collection methods
  • Perform chart reviews
  • Participate in CMS audits of our Risk Adjustment activities
  • Be an expert on all things related to Risk Adjustment and HEDIS
  • Help with the tracking and reporting of identified compliance questions, issues, audits, and investigations through the use of compliance tracking software
  • Use the compliance tracking tools, to include the monitoring of data entered into the system to ensure accuracy, managing data entry workflows and manuals and providing additional training to users
  • Provide feedback and education on coding practices identified during routine audits
  • Conduct special studies/projects as requested by Senior Management and identify opportunities for operational improvements consistent with Oscar's strategic goals
  • Help with the maintenance and creation of procedures relating to the Compliance program at Oscar, and participate in the oversight of all Oscars departmental policies to ensure compliance with established State and Federal regulations
  • Ensure data submitted by Risk Adjustment and HEDIS teams is complete and accurate
  • Ensure financial impact to the organization is accurate and mitigate risk of regulatory agency audits by validating data submitted for Risk Adjustment and HEDIS measures
  • Oversee daily operations on the In Home Health Assessment program and vPCP Program
  • Perform external provider audits on risk adjustment and performing internal audits on Risk Adjustment and HEDIS department's medical record reviews
Desired Qualifications
  • PAHM or other health care related certification
Oscar Health

1,001-5,000 employees

Health insurance company
Company Overview
Oscar Health’s mission is to make high-quality health insurance accessible and affordable for everyone. The company is a software driven health insurance company that offers medical plans, medicare advantages, and small group products.
  • Health insurance - That’s a given. Employees and their families receive incredible health insurance.
  • Financial benefits - A penny saved....we’re talking about a 401K plan, health savings accounts, and more.
  • Well @ Oscar - We care about your wellness with fitness classes and access to mental health support.
  • Work-Life Balance - We offer multiple time-off options, wellness days, and 10+ weeks of parental leave.
  • Learning & Development - We offer everything from mentorship to management training.
Company Values
  • What we do is a big deal. We’re solving problems that change and save lives.
  • Powered by people. Members above all. Developing and growing others is what raises the bar.
  • No genius without grit. Be relentless. Be scrappy. Trying and failing beats not trying and changing nothing.
  • Seek the truth... but never assume you’ve found it. Be scientific.
  • Inspire & provoke. Develop and display leadership at all levels. Fight to be the best.
  • Be transparent. Give and ask for direct feedback. Be grateful for and excited by the help of others.
  • Make it right. Admit your mistakes. Then learn from them. Never build alone.