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Medicare Risk Adjustment Audit Jobs in Virginia (NOW HIRING)

Sentara Health

Risk Adjustment Coder

Virginia Beach, VA · Hybrid

$10K/mo

... for Medicare & Medicaid Services (CMS) and U.S. Department of Health & Human Services (HHS ... Supports risk adjustment data validation (RADV), medical record retrieval, vendor coding audits ...

Humana

Medical Coding Educator

Richmond, VA · On-site

$27 - $30.75/hr

Will report to the Manager, Medicare Risk Adjustment. As the Medical Coding Educator 2 you will ... Analyze coding audit results and other relevant data to develop data-driven educational materials ...

New

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.

Risk Adjustment Coder

Sentara Health

Virginia Beach, VA • Hybrid

$10K/mo

Full-time

Medical, Dental, Vision, Life, Retirement, PTO

Posted 9 days ago

Sentara Health rating

6.8

Company rating: 6.8 out of 10

Based on 398 frontline employees who took The Breakroom Quiz

491st of 887 rated healthcare providers

Job description

City/State
Virginia Beach, VA
Work Shift
First (Days)
Overview:
Sentara Medical Group is now hiring a full-time hybrid Risk Adjustment Coder in Virginia Beach, VA!
Hours:Monday - Friday, 8:00AM -5:00PM, dayshift.
This is a hybrid position that offers a combination of remote and onsite work, with a requirement to be in the office one to two days each week. The role also includes travel as needed to support business objectives and team collaboration.
Overview
Performs compliance activities focused on risk adjustment in accordance with Centers for Medicare & Medicaid Services (CMS) and U.S. Department of Health & Human Services (HHS). Performs prospective/retrospective medical record reviews (MMR) & CMS/HHS Risk Adjustment Data Validation (RADV) audits. Reviews provider coding for professional & inpatient/outpatient services to ensure capture of diagnostic conditions supported within the provider's documentation for CMS/HHS Hierarchical Condition Categories (HCC). Supports risk adjustment data validation (RADV), medical record retrieval, vendor coding audits, provider engagement, & all risk adjustment ICD-10-CM coding-related activities. Conducts annual risk assessments, training, monitoring, & auditing, control assessment, reporting, investigation, root cause analysis, and corrective action oversight. Performs vendor quality oversight audits; reviews and/or makes final coding determination for non-agreeable coding. Makes final decision on vendor-to-vendor diagnosis coding rebuttal concerns. Serves as subject matter expert on risk adjustment diagnosis coding guidelines. Coordinates risk adjustment gap elimination with clinical and quality gap elimination Maintains a reasonable fluency in workings & financial implications of applicable risk adjustment models.
Education
  • Associate degree ( Required )

Experience
  • Medical Records Data - 1 year ( Required )
  • Coding - 2 years ( Required )

Certifications:
One of the following certifications are required: Certified Professional Coder (CPC), Certified Outpatient Coder (COC), Certified Inpatient Coder (CIC), Certified Coding Specialist-Physician-based (CCS-P), Certified Coding Specialist (CCS), Registered Health Information Technician (RHIT), or Registered Health Information Administrator (RHIA).
Must obtain Certified Risk Adjustment Coder (CRC) certification within two years of employment.
Keywords: Risk Adjustment Coding & Documentation Specialist, Talroo-Allied Health, Medical Office
Benefits: Caring For Your Family and Your Career
• Medical, Dental, Vision plans
• Adoption, Fertility and Surrogacy Reimbursement up to $10,000
• Paid Time Off and Sick Leave
• Paid Parental & Family Caregiver Leave
• Emergency Backup Care
• Long-Term, Short-Term Disability, and Critical Illness plans
• Life Insurance
• 401k/403B with Employer Match
• Tuition Assistance - $5,250/year and discounted educational opportunities through Guild Education
• Student Debt Pay Down - $10,000
• Reimbursement for certifications and free access to complete CEUs and professional development
•Pet Insurance
•Legal Resources Plan
•Colleagues have the opportunity to earn an annual discretionary bonus ifestablished system and employee eligibility criteria is met.
Sentara Health is an equal opportunity employer and prides itself on the diversity and inclusiveness of its close to an almost 30,000-member workforce. Diversity, inclusion, and belonging is a guiding principle of the organization to ensure its workforce reflects the communities it serves.
In support of our mission “to improve health every day,” this is a tobacco-free environment.
For positions that are available as remote work, Sentara Health employs associates in the following states:
Alabama, Delaware, Florida, Georgia, Idaho, Indiana, Kansas, Louisiana, Maine, Maryland, Minnesota, Nebraska, Nevada, New Hampshire, North Carolina, North Dakota, Ohio, Oklahoma, Pennsylvania, South Carolina, South Dakota, Tennessee, Texas, Utah, Virginia, Washington, West Virginia, Wisconsin, and Wyoming.

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