Coding Compliance Auditor

Date: Sep 3, 2021

Location: Rancho Cucamonga, CA, US

Company: Inland Empire Health Plans

Job Requisition ID: 5368 


Position Summary/Position


Under the direction of the Manager of Risk Adjustment Informatics, this position is responsible for implementing strategies for successful risk adjustment data validations and enforcing coding standards based on guidelines provided by CMS for risk adjustment.  The Coding Compliance Auditor is responsible for refining tools and training materials to ensure the success of risk adjustment initiatives and Medi-Cal coding programs.  The Coding Compliance Auditor is responsible for supporting all Risk Adjustment Data Validation (RADV) related programs and conducting analytical studies that ensure accuracy and completeness of data submitted to CMS.  The Coding Compliance Auditor runs ongoing reports and analyzes outcomes for potential coding errors and coding gaps.  The Coding Compliance Auditor is responsible for participating in the development of coding improvement project plans and ensuring timely implementation of coding activities within the project plan.  The Coding Compliance Auditor is responsible for supporting all CMS RADV activities including serving as subject matter expert on coding related standards. The Coding Compliance Auditor works collaboratively with internal and external teams to achieve the goals and objectives as it relates to encounter data validation activities.

Major Functions (Duties and Responsibilities)


1. Serves as a subject matter expert on all coding and billing standards for IEHP
2. Helps establish standard work that ensures network compliance with RADV standards and improvements in risk score reporting
3. Responsible for educating and advising providers and practice staff in Medicare coding guidelines, focusing on revenue enhancement opportunities
4. Helps develop plans and materials that support coding education and billing system changes to meet practice and IPA revenue goals
5. Helps develop training/coaching materials and implements training/coaching plans with providers and internal staff
6. Identifies coding gaps in provider documentation to inform targeted educational and remediation activities
7. Monitors changes to CMS coding criteria for HCCs each calendar year and updates IEHP materials and standard work to align with changes
8. Helps develop and implements processes and procedures to ensure accuracy, completeness, and compliance with CMS regulations and guidelines for risk adjustment
9. Maintains appropriate tools, methods, and processes that mitigate potential financial risks to IEHP from errors or audit failures of risk adjustment diagnoses and supporting documents
10. Anticipates and meets, or exceeds, internal and/or external customer expectations and requirements; establishes and maintains effective relationships with customers and gains their trust and respect.
11. Other duties as assigned with or without accommodation.

Supervisory Responsibilities

Leading: Self

Experience Qualifications


At least five (5) years active coding experience with Medicare HCC Risk Adjustment program. At least five (5) years of experience working in risk adjustment division in the healthcare industry. Must have direct experience with risk adjustment data validations. Must have expert fluency and proficiency with CMS Risk Adjustment Methodology.

Education Qualifications


Bachelor’s degree in Healthcare Administration, Healthcare Management or related field from an accredited institution required. 

Professional Certification


Active CCS, CCS-P, CPC, CPC-H CPMA or CRC credential.

Drivers License Required

Yes, must have a valid California Driver's License.

Knowledge Requirement


Ability to identify valid sources and requirements for data submission to CMS. Ability to perform chart review and abstract diagnoses codes by following Official Coding and Risk Adjustment Guidelines. Expert knowledge of all code sets including ICD-10-CM, CPT, CPT-II, HCPCS and E&M. Proficiency in Medi-Cal and Medicare Coding. Proficient in inpatient and outpatient coding practices.

Skills Requirement


Strong verbal and written communication skills. Proficiency with PC based systems, and the ability to learn others.

Abilities Requirement


Ability to work well with others across various levels and areas within the organization. Word processing involving computer keyboard and screens, automobile travel within the Inland Empire. Ability to abide by IEHP’s policies. Maintain confidentiality and comply with Health Insurance Portability and Accountability Act (HIPAA).

Commitment to Team Culture


The IEHP Team environment requires a Team Member to participate in the IEHP Team Culture. A Team Member demonstrates support of the Culture by developing professional and effective working relationships that include elements of respect and cooperation with Team Members, Members and associates outside of our organization.

Working Conditions


While performing the duties of this job, the employee is occasionally required to stand; walk; sit; use hands to finger, handle, or feel objects, tools or controls; reach with hands and arms; climb stairs; balance; stoop, kneel, crouch or crawl; talk or hear; and taste or smell. The employee must occasionally lift or move up to 25 pounds. Specific vision abilities required by the job include close vision, distance vision, color vision, peripheral vision, depth perception and the ability to adjust focus. Maintain regular attendance based on agreed-upon schedule.


Starting Salary: $75,296.00  - $95,992.00  

Pay rate will commensurate with experience


Inland Empire Health Plan (IEHP) is the largest not-for-profit Medi-Cal and Medicare health plan in the Inland Empire. We are also one of the largest employers in the region. With a provider network of more than 6,000 and a team of more than 2,000 employees, IEHP provides quality, accessible healthcare services to more than 1.2 million members. And our mission and core values help guide us in the development of innovative programs and the creation of an award winning workplace. As the healthcare landscape is transformed, we’re ready to make a difference today and in the years to come. Join our Team and Make a Difference with us! IEHP offers a Competitive salary and a benefit package with a value estimated at 35% of the annual salary, including medical, dental, vision, team bonus, and retirement plan.


Nearest Major Market: Riverside
Nearest Secondary Market: Los Angeles