Job Summary
The Risk Adjustment Compliance Auditor, MARA (Medicare Advantage Risk Adjustment) Audit is responsible for providing compliance audit results, feedback, and coaching to the Audit team to ensure compliance with the Centers for Medicare and Medicaid Services (CMS) risk adjustment data submission activities that support accurate medical record documentation, claim, pharmacy, and enrollment data transmission. These activities are critical to support risk score accuracy and, in turn, CMS revenue payment and payment adjustments. The Compliance Auditor, MARA Audit will perform focused compliance audits of personnel and vendors performing the day to day risk adjustment audit oversight for Florida Blue Medicare, which includes risk based audits for internal coders/auditors and vendors and compliance with CMS requirements for risk adjustment data submission and data validation (RADV) activities. These activities are critical to support data submission accuracy and compliance and, in turn, CMS revenue payment and payment adjustments. This Compliance Auditor, MARA Audit role must ensure that audits are performed as part of monitoring and oversight activities to promote correct coding, consistency of coding between vendor coders and internal coders, as well as adherence to Internal Coding Guidelines and compliance requirements. This position is responsible for identifying and addressing issues or trends, and supporting the development of internal control structures and monitoring & oversight to mitigate risk adjustment program-related risks to the organization and will work closely with the coding trainer, compliance team, and audit team to share results and discuss noted trends so that corrective action can be implemented to mitigate risk of inaccuracies in coding.
Essential Functions
- Audit Support
§Oversee audits of operations/personnel for Medicare Advantage and CMS Risk Adjustment Data Validation risk adjustment programs. Audit the auditor activities and vendor audit activities.
§ Track, monitor and report audit coding activities to ensure accurate/timely deliverables and achieve inventory deadlines.
§ Coordination and collaboration with internal/external business partners to optimize resources for audit activities and collaboration regarding coding guidance. This includes participation in BCBS Association meetings to understand industry wide concerns related to coding accuracy.
§ Development of audit programs. Mostly risk-based audits and focused audits.
§ Provide updates to Sr. Leadership on potential concerns, barriers; consult regarding identified trends and issues with focus on identifying root cause.
§ Identify, manage and report defects and exceptions in the workflow and seek solutions to reduce impacts to the audit process and workflows
- Training Support
• Working with the Lead Trainer to ensure all staff are trained correctly, timely and efficiently to include changes and/or enhancements to information and productivity tools for audit activities.
• Prepare for and facilitate staff meetings.§ Provide feedback and coaching as well as assistance in developing resources to enable culture of compliance.
§ Create and enable a learning environment that supports and encourages development, personal growth and assuming greater responsibility
- Operational Support
§ Seeks clarification on and communicates CMS regulations and reimbursement methodologies, utilize detailed analyses, and communicate with internal and external auditors for audit activities.
§ Support coding and medical documentation compliance audits in support of vendor and provider performance management.
§ Maintain relationships with audit customers at appropriate levels and promote teamwork and responsibility with engagement team members.
§ Assist in identifying risks, evaluating controls and preparing audit reports.
§ Apply the risk adjustment controls in place to optimize operational effectiveness.
§ Seek and communicate opportunities to continually improve efficiencies and meet CMS regulations and requirements.
§ Lead or participate in the review and development of policies, guidelines and standard operating procedures of the department.
§ Lead or support external audits from federal government agencies related to risk adjustment data validation.
- Process Improvement and Collaboration
§ Lead or support continuous improvement, creativity and innovation is embedded in the culture of MARA Compliance department.
§ Determine, gain agreement and implement improvements based upon trends and issues impacting the accuracy of CMS submission data.
§ Support an environment that encourages new ideas, designs and approaches to situations and problems.
§ Monitor, evaluate and provide feedback on new processes, designs, etc. to enable additional improvements.
§ Build strong working relationships that cross business sector and organization boundaries to ensure business objectives are met and issues resolved.
§ Coordinate with peers, colleagues and leaders across organizational lines to enhance compliance with CMS requirements.
Qualifications:
• Required Work Experience
4+ years related work experience. Experience Details: Coding experience
• Required Management Experience
No supervisory/management experience required
• Required Education
Related Bachelor’s degree or additional related equivalent work experience
• Required Licenses and Certifications
An active coding credential or designation (COC, CPC, CPMA, CRC, CCS or CCM) from the American Association of Professional Coders (AAPC) or American Health Information Management Association (AHIMA) Upon Hire
Certified Risk Adjustment Coder (CRC) designation 1 Year
• Experience in healthcare/managed care operations, Medicare
Knowledge of and ability to coach management team on the following service tools, processes and programs:
o CMS regulatory requirements and reimbursement methodologies
o Internet research capabilities and tools
o Data research and analysis processes
Demonstrated experience in coding, chart review, and data validation.
• Knowledge of CMS guidelines and reporting requirements
• Communication skills
• Presentation skills (presenting complex and technical information to audiences with diverse knowledge base)
• Knowledge of continuous improvement principles and tools
• Preferred Education
Bachelor’s degree
General Physical Demands
Sedentary work: Exerting up to 10 pounds of force occasionally to move objects. Jobs are sedentary if traversing activities are required only occasionally.
Physical/Environmental Activities
Must be able to travel to multiple locations for work (i.e. travel to attend meetings, events, conferences). Occasionally
What We Offer:
As a Florida Blue employee, you will thrive in our Be Well, Work Well, GuideWell culture where being well as an individual, and working well as a team, are both important in serving our members and communities.
To support your wellbeing, comprehensive benefits are offered. As an employee, you will have access to:
- Medical, dental, vision, life and global travel health insurance;
- Income protection benefits: life insurance, Short- and long-term disability programs;
- Leave programs to support personal circumstances;
- Retirement Savings Plan includes employer contribution and employer match;
- Paid time off, volunteer time off, and 11 holidays
- Additional voluntary benefits available; and
- A comprehensive wellness program
Employee benefits are designed to align with federal and state employment laws. Benefits may vary based on the state in which work is performed. Benefits for intern, part-time and seasonal employees may differ.
To support your financial wellbeing, we offer competitive pay as well as opportunities for incentive or commission compensation. We also conduct regular annual reviews with pay for performance considerations for base pay increases.
Annualized Salary Range: $66,400 – $107,900
Typical Annualized Hiring Range: $66,400 – $83,000
Final pay will be determined with consideration of market competitiveness, internal equity, and the job-related knowledge, skills, training, and experience you bring.
We are an Equal Opportunity/Protected Veteran/Disabled Employer committed to creating a diverse, inclusive and equitable culture for our employees and communities.