Auditor, Risk Adjustment

Oscar

Associate Risk Adjustment Auditor for Oscar Health managing quality audits and risk adjustment processes. Collaborates with management to maintain compliance and improve coding standards.

Posted 5/29/2026full-timeRemote • Arizona, Florida, Texas • 🇺🇸 United StatesMid-LevelSenior💰 $82,717 - $108,566 per yearWebsite

About the role

Key responsibilities & impact

Responsible for daily operations pertaining to Risk Adjustment including but not limited to: medical record reviews to report ICD-10-CM diagnosis codes for ACA and MA lines of business, potential Centers of Medicare & Medicaid Services (CMS), Health and Human Services (HHS) audits and medical record retrieval efforts.
Mitigate risk by validating Encounter Data Gathering Environment Server (EDGE) data is supported within provider encounter documentation
Review the performance of the Risk Adjustment Coding team and report audit trends to Leadership in a timely, consistent and effective manner to ensure the appropriate changes and education are implemented.
Maintain compliance with national standards and coding practices set by the ICD-10-CM coding guidelines for accuracy, as well as compliance with Risk adjustment production standards.
Conduct CMS audits of Risk Adjustment activities, including but not limited to Risk Adjustment Data Validation audits.
Develop relationships with key individuals to foster an increased understanding of the Risk Adjustment process.
Identify and execute on the creation of clinical document improvement resources for provider education in both MA and ACA line of business.
Manage the implementation process improvements that will maximize risk adjustment factor increases.
Compliance with all applicable laws and regulations
Other duties as assigned

Requirements

What you’ll need

Bachelor's degree in a relevant field of study or commensurate work experience.
Certified professional coder (CPC)
3+ year(s) retrospective risk adjustment coding experience.
1+ year(s) experience Quality Auditing and/or Risk Adjustment Data Validation Audit (RADV) experience

Benefits

Comp & perks

employee benefits
participation in Oscar's unlimited vacation program
annual performance bonuses

ATS Keywords

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Applicant Tracking System Keywords

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Hard Skills & Tools

ICD-10-CM codingRisk Adjustment codingQuality AuditingRisk Adjustment Data Validation Audit (RADV)Encounter Data Gathering Environment Server (EDGE)medical record reviewsdata validationcompliance standardsclinical document improvementprocess improvements

Soft Skills

leadershipcommunicationrelationship buildingtimelinesseffectivenessorganizational skillsproblem-solvingeducation implementationtrend reportingcollaboration

Certifications

Certified Professional Coder (CPC)