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Medicare Risk Adjustment Audit Jobs (NOW HIRING)

Oscar Health

Auditor, Risk Adjustment

Tempe, AZ · Remote

$82K - $108K/yr

We're hiring a Associate, Risk Adjustment Auditor to join our Risk Adjustment team. Oscar is the ... Medicare & Medicaid Services (CMS), Health and Human Services (HHS) audits and medical record ...

Oscar Health

Auditor, Risk Adjustment

Miami, FL · Remote

$82K - $108K/yr

We're hiring a Associate, Risk Adjustment Auditor to join our Risk Adjustment team. Oscar is the ... Medicare & Medicaid Services (CMS), Health and Human Services (HHS) audits and medical record ...

Oscar Health

Auditor, Risk Adjustment

Atlanta, GA · Remote

$82K - $108K/yr

We're hiring a Associate, Risk Adjustment Auditor to join our Risk Adjustment team. Oscar is the ... Medicare & Medicaid Services (CMS), Health and Human Services (HHS) audits and medical record ...

Oscar Health

Auditor, Risk Adjustment

Dallas, TX · Remote

$82K - $108K/yr

We're hiring a Associate, Risk Adjustment Auditor to join our Risk Adjustment team. Oscar is the ... Medicare & Medicaid Services (CMS), Health and Human Services (HHS) audits and medical record ...

Strive Health

Risk Adjustment Coder

Denver, CO · Remote

$27.88 - $32.21/hr

This individual will assist in special coding audits and coding projects as necessary and provide ... Extensive knowledge of documentation and coding guidelines established by the Center for Medicare ...

Medica

Senior Director Risk Adjustment

Governance, Compliance, and Audit Readiness * Establish and maintain governance structures that ... At least 8-10 years of direct experience in Risk Adjustment across Medicare Advantage, Medicaid ...

Imedica

Senior Director Risk Adjustment

Minnetonka, MN · On-site

Governance, Compliance, and Audit Readiness * Establish and maintain governance structures that ... At least 8-10 years of direct experience in Risk Adjustment across Medicare Advantage, Medicaid ...

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All JobsMedicare Risk Adjustment Audit Jobs

Medicare Risk Adjustment Audit information

See salary details

$31K

$89.7K

$126.5K

How much do medicare risk adjustment audit jobs pay per year?

As of Jun 8, 2026, the average yearly pay for medicare risk adjustment audit in the United States is $89,650.00, according to ZipRecruiter salary data. Most workers in this role earn between $65,500.00 and $116,500.00 per year, depending on experience, location, and employer.

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.
More about Medicare Risk Adjustment Audit jobs
What cities are hiring for Medicare Risk Adjustment Audit jobs? Cities with the most Medicare Risk Adjustment Audit job openings:
What states have the most Medicare Risk Adjustment Audit jobs? States with the most job openings for Medicare Risk Adjustment Audit jobs include:
What job categories do people searching Medicare Risk Adjustment Audit jobs look for? The top searched job categories for Medicare Risk Adjustment Audit jobs are:
Medicare Risk Adjustment Audit jobs near you
Infographic showing various Medicare Risk Adjustment Audit job openings in the United States as of May 2026, with employment types broken down into 96% Full Time, and 4% Contract. Highlights an 78% In-person, 2% Hybrid, and 20% Remote job distribution, with an average salary of $89,650 per year, or $43.1 per hour.
Informatics Risk Adjustment Consultant

Informatics Risk Adjustment Consultant

HealthPartners

Saint Paul, MN • On-site

Other

Medical, Retirement

Posted 29 days ago

HealthPartners rating

7.8

Company rating: 7.8 out of 10

Based on 127 frontline employees who took The Breakroom Quiz

103rd of 869 rated healthcare providers

Job description

HealthPartners is hiring a Informatics Risk Adjustment Consultant.  The Informatics Consultant -supports the Health Plan's risk adjustment operations by delivering trusted, prioritized, and compliant data insights that drive efficient workflows and improve risk score accuracy, while continuously refining processes through feedback. This role ensures the plan's risk adjustment outputs are accurately represented in claims and encounter data, analytics, and reporting.

The consultant serves as a bridge between the data/technology teams and risk adjustment operations, clinical/provider stakeholders, coding and chart review teams, and compliance/audit partners. The role enables informed, compliant, and actionable risk adjustment program, while maintaining strong governance, audit readiness, and organizational standards.

ACCOUNTABILITIES:  

Risk Adjustment Strategy & Program Execution

  • Support planning and execution of annual risk adjustment initiatives (prospective, concurrent, and retrospective), aligned to plan goals and regulatory requirements.
  • Translate risk adjustment priorities into practical workflows, playbooks, and measurable interventions across provider groups and vendor partners.
  • Partner with risk adjustment operations to optimize data capture, risk score modeling, member stratifications, suspecting logic, and program outcomes.

Diagnosis Accuracy, Clinical Validity & Documentation Integrity

  •  
  • Identify patterns of under-capture, over-capture, and potential diagnosis coding inaccuracies; drive suspecting logic and workflow improvements.
  • Support provider-facing reporting 

Encounter & Claims Data Quality (Core Health Plan Focus)

  • Work with operational and technical teams to improve completeness, timeliness, and accuracy of encounter data and diagnosis submission (including resolving rejections, edit failures, and submission gaps).
  • Define and monitor data quality KPIs (e.g., encounter internal validations, submission rates, acceptance rates, diagnosis completeness, provider group variation, lag time).

Provider & Vendor Enablement (External-Facing Consulting)

  • Support relationships with provider groups, delegated entities, and vendor partners to improve data exchange and workflows
  • Participate in vendor management activities (requirements gathering, performance monitoring, issue escalation, and continuous improvement).

Measurement, Analytics & Performance Reporting

  • Define and track risk adjustment performance measures such as:
    • Reconfirmation rates and suspected-condition confirmation rates
    • Member visit rates and provider engagement
    • Condition prevalence shifts and variation analysis
    • Net risk score movement (where appropriate) with integrity guardrails, and drivers of risk
    • Encounter submission acceptance rates 
    • Audit results and feedback loop reporting
  • Partner with analytics teams to develop dashboards and actionable reporting (e.g., Power BI), and to ensure consistent measure definitions.

Compliance, Audit Readiness & Governance

  • Partner with compliance, internal audit, and risk adjustment leadership to support audit readiness (e.g., documentation standards, monitoring, validation processes).
  • Help implement controls and monitoring to identify outliers and reduce risk (e.g., unusual provider patterns, unsupported diagnoses, excessive suspecting false positives).
  • Maintain familiarity with current risk adjustment policies and guidance, and support operational implementation of updates.

Cross-Functional Leadership & Change Management

  • Facilitate collaboration between data/technology teams and risk adjustment operations, clinical/provider stakeholders, coding and chart review teams, and compliance/audit partners.

  • When asked, co-lead small to medium initiatives end-to-end, including requirements definition, workflow design, stakeholder engagement, training, measurement, and sustainment.

    REQUIRED QUALIFICATIONS:  

1. Education

  • Bachelor's degree in health informatics, nursing, health information management, public health, business, or related field; or equivalent combination of education and experience.

2. Experience and Knowledge

  • 5+ years of experience in health plan and/or risk adjustment-related domains, such as: risk adjustment operations, encounter data management, coding, clinical documentation integrity, provider performance, quality improvement, or healthcare analytics.
  • Working knowledge of how diagnoses flow through EHR coding/chart review encounter/claims submission risk adjustment analytics.
  • Experience collaborating with provider organizations and/or delegated entities to improve documentation and data submission practices.
  • Experience using data to drive improvement: ability to interpret trends, variation, root cause issues, and performance metrics.
  • Familiarity with Medicare Advantage (preferred) and/or other risk programs, including chart review concepts and audit sensitivity.

3. Skills

  • Strong consulting, facilitation, and stakeholder management skills; able to influence without authority.
  • Excellent written and verbal communication; able to create clear playbooks, training, and executive-ready summaries.
  • Strong analytical thinking and operational problem-solving; comfortable navigating ambiguous issues across workflows and systems.
  • High integrity and sound judgment; commitment to compliant, clinically appropriate documentation practices.
  • Strong project management skills; ability to manage multiple workstreams, deadlines, and cross-functional dependencies.

PREFERRED QUALIFICATIONS:

  • Credentials such as CRC, CPC, CCS, CDIP, CCDS (or comparable).
  • Experience working directly with MA encounter submission processes, edit resolution, or encounter data ingestion/validation.
  • Experience supporting chart retrieval/coding vendors and performance management (KPIs, SLAs, escalation paths).
  • Familiarity with audit processes and documentation standards (e.g., retrospective validation, risk adjustment audits), and designing monitoring/controls.
  • Experience developing or specifying requirements for dashboards and operational reporting (Power BI, Tableau, or equivalent).
  • Solid working experience with SQL and relational database design
  • Exposure to agile/scrum
  • Experience using Azure suite of tools, Databricks, Azure Data Lake
  • Experience in a highly regulated environment and comfort partnering closely with compliance and privacy.

At HealthPartners we believe in the power of good - good deeds and good people working together. As part of our team, you'll find an inclusive environment that encourages new ways of thinking, celebrates differences, and recognizes hard work.

We're a nonprofit, integrated health care organization, providing health insurance in six states and high-quality care at more than 90 locations, including hospitals and clinics in Minnesota and Wisconsin. We bring together research and education through HealthPartners Institute, training medical professionals across the region and conducting innovative research that improve lives around the world.

At HealthPartners, everyone is welcome, included and valued. We're working together to increase diversity and inclusion in our workplace, advance health equity in care and coverage, and partner with the community as advocates for change.

Benefits Designed to Support Your Total Health
As a HealthPartners colleague, we're committed to nurturing your diverse talents, valuing your dedication, and supporting your work-life balance. We offer a comprehensive range of benefits to support every aspect of your life, including health, time off, retirement planning, and continuous learning opportunities. Our goal is to help you thrive physically, mentally, emotionally, and financially, so you can continue delivering exceptional care.

Join us in our mission to improve the health and well-being of our patients, members, and communities.

We are an Equal Opportunity Employer and do not discriminate against any employee or applicant because of race, color, sex, age, national origin, religion, sexual orientation, gender identify, status as a veteran and basis of disability or any other federal, state or local protected class.

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