Job Title: Quality Review and Audit Analyst
Location: Remote (EST Hours)
Duration: 03 Months (Possible extension based on business needs)
Schedule Notes:

• Standard Schedule: Monday to Friday | 9:00 AM – 5:00 PM EST
• Training Schedule: 2 Weeks | 9:00 AM – 5:00 PM EST
• Post-Training Flex: Start time between 7:00 AM and 9:00 AM EST (8-hour consecutive shift required)

 Screening Questions:

1. Do you have at least two (2) years of recent experience in Risk Adjustment and HCC coding?
2. Which active AHIMA or AAPC certification(s) do you currently hold?
3. How would you describe your proficiency in Microsoft Office tools, particularly Excel and Word?
4. Do you have experience with ICD-10-CM coding, chart reviews, and risk adjustment audits?
5. Are you familiar with CMS regulations for Risk Adjustment in both inpatient and outpatient settings?

 Responsibilities:

• Conduct medical records reviews with accurate diagnosis code abstraction in accordance with Official Coding Guidelines and Conventions, Client IFP Coding Guidelines, HHS Protocols, and other applicable rules.
• Utilize HHS’ Risk Adjustment Model to confirm accuracy of Hierarchical Condition Categories (HCC) identified from ICD-10-CM diagnosis codes for the correct Benefit Year.
• Apply longitudinal thinking to identify all valid and appropriate data elements and opportunities for capture through the lens of HHS Risk Adjustment.
• Perform documentation and data audits, identifying gaps/inaccuracies in risk adjustment data and compliance risks to support IFP Risk Adjustment (RA) programs, including:

• Risk Adjustment Data Validation (RADV) audit
• Supplement Diagnosis Submission Program
• Quality audits of vendor coding partners
• Collaborate and coordinate with internal and external partners on coding and Risk Adjustment education.
• Coordinate with stakeholders to execute compliant RA programs, raising any identified risks or gaps to management.
• Communicate effectively across all audiences (both verbal and written).
• Assist in the development and implementation of internal program processes to ensure CMS/HHS compliance, including contributions to Client IFP Coding Guideline updates.

Skills/Requirements:

• Excellent written and verbal communication skills
• Experience with medical documentation audits and chart reviews
• Strong knowledge of ICD-10-CM coding guidelines and conventions
• Detail-oriented, self-motivated, organized
• Preferred: Understanding of medical claims submission
• Ability to meet timeline, productivity, and accuracy standards
• Experience working in a remote environment

Education & Certification:

• High school diploma required
• Must have one of the following AHIMA or AAPC certifications:

• Certified Professional Coder (CPC)
• Certified Coding Specialist – Provider (CCS-P)
• Certified Coding Specialist – Hospital (CCS-H)
• Registered Health Information Technician (RHIT)
• Registered Health Information Administrator (RHIA)
• Certified Risk Adjustment Coder (CRC)

Must-Haves:

• Recent two-plus years of Risk Adjustment/HCC coding experience.
• Active AHIMA or AAPC certification (CPC, CCS-P, CCS-H, RHIT, RHIA, or CRC).
• Proficiency in Microsoft Office tools (Excel, Word, etc.).
• Experience with ICD-10-CM coding, chart reviews, and risk adjustment audits.
• Familiarity with CMS regulations for Risk Adjustment (Inpatient and Outpatient).

Additional Requirements:

• 100% Remote – candidates must be located in the U.S. and support EST hours.
• Quiet, private working environment required.
• Reliable, high-speed internet connection required.
• No pre-planned/scheduled time off allowed during the first 30 days.

 

 


At SPECTRAFORCE, we are committed to maintaining a workplace that ensures fair compensation and wage transparency in adherence with all applicable state and local laws. This position’s starting pay is: $29.31/hr.