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Medicare Risk Adjustment Audit Jobs in Virginia (NOW HIRING)

Ennoble Care

Actuary

Richmond, VA · Remote

$150/hr

Thorough understanding of and hands-on experience with Medicare risk adjustment and CMS-HCC models * Experience working with CMS and CMMI total cost of care (ACO) programs * Proven track record ...

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Medicare Risk Adjustment Audit information

What are the key skills and qualifications needed to thrive as a Medicare Risk Adjustment Auditor, and why are they important?

To thrive as a Medicare Risk Adjustment Auditor, you need expertise in medical coding, healthcare compliance, and an understanding of CMS risk adjustment guidelines, often supported by a coding certification such as CPC or CRC. Familiarity with auditing software, electronic health records (EHRs), and data analytics tools is typically required. Attention to detail, analytical thinking, and strong communication are essential soft skills for reviewing documentation and conveying findings. These skills are crucial for ensuring accurate risk adjustment coding, regulatory compliance, and optimized reimbursement for healthcare organizations.

What are some common challenges faced by professionals in Medicare Risk Adjustment Audit roles, and how can they be addressed?

Professionals in Medicare Risk Adjustment Audit roles often encounter challenges such as interpreting complex medical documentation, staying updated on evolving CMS guidelines, and ensuring data accuracy for compliant risk scoring. Effective collaboration with coders, providers, and compliance teams is essential to resolve discrepancies and achieve audit objectives. Staying proactive in ongoing training and leveraging audit technologies can help address these challenges and contribute to high-quality, compliant results.

What is the difference between Medicare Risk Adjustment Audit vs Medicare Coding Specialist?

AspectMedicare Risk Adjustment AuditMedicare Coding Specialist
Primary FocusReviewing and verifying accuracy of risk adjustment dataAssigning correct medical codes for billing and documentation
CertificationsRisk adjustment or auditing certifications often preferredMedical coding certifications like CPC or CCS
Work EnvironmentHealthcare organizations, insurance companies, auditing firmsHospitals, clinics, billing companies
Industry UsageUsed in Medicare Advantage plan compliance and reimbursementUsed in medical billing and claims processing

While both roles involve healthcare data, Medicare Risk Adjustment Auditors focus on verifying the accuracy of risk scores for Medicare payments, whereas Medicare Coding Specialists assign medical codes for billing purposes. Understanding these differences helps in choosing the right career path or job focus within the healthcare industry.

What is a Medicare Risk Adjustment Audit?

A Medicare Risk Adjustment Audit is a review process conducted to ensure that healthcare providers are accurately reporting patient diagnoses to Medicare Advantage plans. This audit verifies that submitted diagnoses are supported by proper medical documentation, which affects how much Medicare pays to health plans. The goal is to prevent overpayments or underpayments and to ensure compliance with federal regulations. These audits are typically performed by the Centers for Medicare & Medicaid Services (CMS) or their contractors.
What are popular job titles related to Medicare Risk Adjustment Audit jobs in Virginia? For Medicare Risk Adjustment Audit jobs in Virginia, the most frequently searched job titles are:
What job categories do people searching Medicare Risk Adjustment Audit jobs in Virginia look for? The top searched job categories for Medicare Risk Adjustment Audit jobs in Virginia are:
Medicare Risk Adjustment Audit jobs near you
Infographic showing various Medicare Risk Adjustment Audit job openings in Virginia as of August 2026, with employment types broken down into 100% Full Time. Highlights an 67% In-person, and 33% Remote job distribution.

Actuary

Ennoble Care

Richmond, VA • Remote

$150/hr

Full-time

Re-posted 22 days ago

Ennoble Care rating

4.2

Company rating: 4.2 out of 10

Based on 6 frontline employees who took The Breakroom Quiz

Job description

About Us

Ennoble Care is a mobile primary care, palliative care, and hospice service provider with patients in New York, New Jersey, Maryland, DC, Virginia, Oklahoma, Kansas, Pennsylvania, Texas, Florida, and Georgia. Ennoble Care's clinicians go to the home of the patient, providing continuum of care for those with chronic conditions and limited mobility. Ennoble Care offers a variety of programs including, remote patient monitoring, behavioral health management, and chronic care management, to ensure that our patients receive the highest quality of care by a team they know and trust. We seek individuals who are driven to make a difference and embody our motto, "To Care is an Honor." Join Ennoble Care today!

Position Overview

We are seeking an experienced Actuary (5+ years of experience) for our value-based care (VBC) team. This role requires a seasoned professional in medical economics, actuarial, or equivalent data analytics experience who can navigate the complex landscape of Medicare risk models, value-based care arrangements, and population health analytics. The ideal candidate will play a critical role in optimizing our organization's performance under CMS total cost of care models while ensuring sustainable financial outcomes. Candidates will ideally have their ASA certification or have passed at least the first three exams.

This role is currently scoped as an individual contributor, with a growth trajectory toward leadership over time.

Key ResponsibilitiesData Management & Medicare Analytics
  • Analyze VBC performance under various CMS and CMMI total cost-of-care models.
  • Monitor and forecast financial performance across assigned patient populations.
  • Conduct comprehensive claims analysis using CCLF (Claims and Claims Line Feed) and BCDA (Beneficiary Claims Data API) datasets.
  • Refine key reporting and projection methodologies, including IBNR and Risk Score projections.
  • Process and analyze large healthcare datasets, combining multiple data sources including EHR systems and Medicare claims data.
  • Ensure data quality and integrity across all analytical processes.
  • Develop and maintain SQL-based data structures to support population experience studies and VBC program analytics.
Business Intelligence & Reporting
  • Create fit-for-purpose analytical reports that translate complex actuarial findings into actionable business insights.
  • Develop executive dashboards and performance metrics aligned with organizational strategic goals.
  • Present findings and recommendations to leadership teams and clinical stakeholders.
  • Support budget planning and financial forecasting processes.
Regulatory Compliance & Process Improvement
  • Stay current with evolving CMS and CMMI program requirements and quality measures.
Required QualificationsEducation & Certification
  • Bachelor's degree in Actuarial Science, Statistics, Mathematics, Data Science, or related quantitative field
  • ASA credentials preferred for Actuarial candidates
Experience Requirements
  • Strong healthcare data analytics experience in Medicare-focused or Medicare Advantage environments (5+ years of experience)
  • Thorough understanding of and hands-on experience with Medicare risk adjustment and CMS-HCC models
  • Experience working with CMS and CMMI total cost of care (ACO) programs
  • Proven track record spearheading claims analytics using Medicare claims data
  • In-depth knowledge of healthcare billing processes from both provider and CMS perspectives
Technical Proficiency
  • Advanced proficiency in Microsoft Excel and model building
  • Strong SQL skills with the ability to write complex queries
  • Experience with the Microsoft Azure cloud platform and related analytics tools preferred
  • Experience with integrating data across multiple large, nuanced data sources (e.g., integration of EHR data with claims datasets)
  • Experience developing/integrating AI-forward workflows into analytics
Core Competencies
  • Exceptional analytical and problem-solving capabilities
  • Strong business acumen with the ability to translate technical findings into strategic recommendations
  • Excellent written and verbal communication skills for both technical and non-technical audiences
  • Proven team player with a collaborative approach to cross-functional projects
  • Demonstrated capability to understand and respond to evolving business needs
Compensation
  • The salary range is $150- 170k with a $30- 40k bonus range

Full-time employees qualify for the following benefits:

  • Medical, Dental, Vision and supplementary benefits such as Life Insurance, Short Term and Long Term Disability, Flexible Spending Accounts for Medical and Dependent Care, Accident, Critical Illness, and Hospital Indemnity.
  • Paid Time Off
  • Paid Office Holidays

All employees qualify for these benefits:

  • Paid Sick Time
  • 401(k) with up to 3% company match
  • Referral Program
  • Payactiv: pay-on-demand. Cash out earned money when and where you need it!

Candidates must disclose any current or future need for employment-based immigration sponsorship (including, but not limited to, OPT, STEM OPT, or visa sponsorship) before an offer of employment is extended.

Ennoble Care is an Equal Opportunity Employer, committed to hiring the best team possible, and does not discriminate against protected characteristics including but not limited to - race, age, sexual orientation, gender identity and expression, national origin, religion, disability, and veteran status.

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