Clinical Auditor, Specialty Programs

Job Description: • Conduct comprehensive audits of clinical documentation to ensure accurate Hierarchical Condition Category (HCC) capture, risk adjustment compliance, and closure of quality gaps. • Validate HCC coding accuracy and completeness in alignment with CMS risk adjustment guidelines. • Review documentation for chronic conditions, preventive care, and quality measures to identify gaps and opportunities for improvement. • Analyze data to detect patterns in coding, documentation, and quality performance and recommend corrective actions. • Collaborate with providers, clinical education teams, and coding staff to educate on best practices for documentation and accurate risk adjustment coding. • Monitor and report on quality gap closure initiatives, including HEDIS and other performance measures. • Prepare detailed audit reports summarizing findings, compliance risks, and actionable recommendations. • Assist in developing and refining audit tools, workflows, and training materials for risk adjustment and quality programs. • Stay current with CMS guidelines, ICD-10 coding updates, and payer-specific requirements for risk adjustment and quality reporting. Requirements: • Associate’s degree in nursing • 3+ years of experience in clinical auditing, risk adjustment, or quality improvement programs • Strong knowledge of HCC coding, ICD-10, and medical terminology • Expertise in risk adjustment methodologies and quality reporting standards (e.g., HEDIS) • Excellent analytical and problem-solving skills • Strong attention to detail and ability to interpret complex clinical documentation • Extensive knowledge of database management and running/interpreting reports • Ability to partner with shared stakeholders to achieve mutual success • Proficient in Microsoft Office, including Outlook, Word, and Excel • Ability to prioritize and multi-task in a fast-paced environment • Ability to foster a collaborative work environment • Interpersonal skills sufficient to effectively communicate both written and orally with department teams, practitioners, and team members • Ability to work independently and manage multiple audits simultaneously • Commitment to compliance, accuracy, and continuous improvement Benefits: • Health, Dental, Vision, Disability & Life Insurance, and much more • 401K Retirement Plan (with company match) • Tuition, Professional License and Certification Reimbursement • Paid Time Off, Holidays and Volunteer Time • Paid Orientation and Training • Great Place to Work Certified Apply tot his job