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Lead Risk Adjustment HEDIS Auditor

To be fully engaged in providing No Harm / Quality, Customer Experience, and Stewardship by: effectively monitoring overall risk adjustment efforts. The individual will be responsible for auditing diagnosis codes discovered by the Government Programs Risk Adjustment Team. The individual will provide superior quality by educating internal staff of errors and opportunities for improvement discovered during routine auditing. This individual will work closely with the Director of Government Programs and the Manager of Risk Adjustment to implement benchmarks, establish acceptable thresholds, and effective quality assurance programs.

Quality/No Harm:

Lead, develop, implement and maintain a quality assurance program for data collected by the Risk Adjustment Team.

Monitor the performance of the Risk Adjustment and Comprehensive Health Assessment Teams and report findings to Senior Leadership in a timely, consistent and effective manner ensuring that appropriate changes are implemented.

Leads the work of Risk Adjustment auditors and clinical coordinators by prioritizing and delegating the daily workload. Handles immediate situations to ensure departmental standards of quality, service and value.

Ensure all issues regarding daily workflow are communicated to the Manager and/or Director.

Assist the manager of Risk Adjustment with input on staff evaluations/competency.

Assumes the duties of the Manager and/or Director in their absence during times of vacation, scheduled days off and leaves of absences.

Manage audit processes ensuring work flows and results are properly documented and maintained. Identify and implement process improvements as needed.

Assist in managing the development of provider audit processes to meet and maintain regulatory/accreditation/operational requirements, including reporting a detailed analysis of the issue, making recommendations and following the outcome.

Maintain confidentiality in regard to individual error results.

Accountable for continuing a culture of compliance with Health First Health Plans and Health First Medical Group core values, policies & procedures and applicable regulatory requirements and standards.

Assist in the development of an effective training program regarding correct coding techniques and data collection methods.

Train new auditors/clinical coordinators as needed.

Perform chart reviews as needed.

Participate in CMS audits of our Risk Adjustment activities, including but not limited to Risk Adjustment Data Validation audits.

Assist with the tracking and reporting of identified compliance questions, issues, audits, and investigations through the use of compliance tracking software

Serve as the system administrator for the compliance tracking software at HFHP, to include the monitoring of data entered into the system to ensure accuracy, developing and maintaining data entry workflows and manuals and providing additional training to users.

Develop and manage a monthly Compliance Program Report to effectively capture current activities, issues, trends, and oversight related to compliance issues within HFHP.


Four year degree from accredited college/university and a minimum of two to four years’ experience in an audit or compliance capacity or a minimum of three years in a position responsible for program compliance and training with some college.

Certified coder with a minimum of two to four year's coding experience.

Expert knowledge of Medicare Risk Adjustment preferred.

Research and problem resolution skills.

Personal computer skills a must, proficient in word processing, graphics and spreadsheet manipulation and basic understanding of the Internet.

Exceptional interpersonal relationship skills.

Demonstrates excellent written and verbal communication skills conforming to all rules of punctuation, grammar, diction and professional style.
Presents professional image to the public.

Experience in initiating, developing and monitoring policies, internal control procedures and operating standards.

Ability to navigate constructive conversations on behalf of the health plan with State and Federal officials.


Organization:HF Administrative Plan Inc

Primary Location:United States-Florida - Brevard County-Rockledge

Time:  Full time
Salary:  Salary
Category:  Operations

Updated: 1/25/2019 1:46:53 PM

Job Contact:
Career Center

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6450 US Highway 1
Rockledge, FL 32955