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Medicare Risk Adjustment Audit Jobs (NOW HIRING)

Vertek Staffing

HCC Risk Adjustment Coder

Franklin, TN · Remote

$18 - $24/hr

Participate in internal and external audit activities. * Stay current on CMS Risk Adjustment ... Experience with Medicare Advantage populations * Experience with value-based care programs

MetroPlusHealth

Risk Adjustment Specialist

Manhattan, NY · Hybrid

$72K - $82K/yr

Position Overview Risk Adjustment is a growing and critical field within Health Insurance Finance ... Medicaid, Medicare and Affordable Care Act/QHP. This includes monitoring submission timelines ...

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Medicare Risk Adjustment Audit information

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$31K

$89.7K

$126.5K

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

As of Sep 1, 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 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 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 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 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.

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 August 2026, with employment types broken down into 1% As Needed, 89% Full Time, 8% Part Time, and 2% Contract. Highlights an 87% Physical, 4% Hybrid, and 9% Remote job distribution, with an average salary of $89,650 per year, or $43.1 per hour.

Risk Adjustment Coder (Hybrid)

Gonzaba Medical Group

San Antonio, TX • On-site

$19.50 - $26/hr

Full-time

Posted 14 days ago

Gonzaba Medical Group rating

5.6

Company rating: 5.6 out of 10

Based on 19 frontline employees who took The Breakroom Quiz

Job description

General Summary: This role focuses on the Risk Adjustment process that supports the documentation of acuity diagnoses for the Managed Care (MC) patient population and required activities for submission of records to Medicare Advantage (MA) payers under established capitated contracts. It assists with medical record reviews for HCC diagnoses, correct usage of various coding guidelines (ICD-10-CM, CPT, HCPCS) and federal and MA payor regulations, as well as clinical validation of appropriate supporting documentation.
Supervisory Responsibilities: This position has no supervisory responsibilities.
General Requirements: All duties performed will be done accurately and in a timely manner.
  1. Assumes responsibility for maintaining clinical competencies according to Gonzaba Medical Group policy.
  2. Exercise tact and courtesy when dealing with patients, visitors, providers, and co-workers.
  3. Must always adhere to customer service expectations including in-person and virtual (via telephone, or telehealth applications) communication.
  4. Participates in other Managed care projects to include but not limited to marketing events, and Medicare Open enrollment period.
  5. Reviews reports to identify areas for improvement or needed action to meet departmental goals.
  6. Supports team members in all aspects of the Risk Adjustment process to ensure that defined timelines and departmental goals are met.
  7. Adhere to all confidentiality and HIPAA requirements as always outlined within Gonzaba Medical Group Operating Policies and Procedures in all ways and with respect to any aspect of the data handled or services rendered.
  8. Other duties as assigned.

Essential Job Responsibilities:
  1. Maintain compliance with Gonzaba Medical Group policies, Official Coding Guidelines and the Gonzaba Medical Group Coder's Pledge.
  2. Provides queries or technical guidance to physicians, clinical staff, and other departmental staff in identifying and resolving issues or errors, such as incomplete or missing records and documentation, ambiguous or nonspecific documentation, or codes that do not conform to approved coding principles/guidelines data in the form of a query, email and or task.
  3. Accurately validate and abstract diagnosis codes from provider documentation in the patient medical record to ensure that reported ICD-10 codes are appropriately supported by the documentation.
  4. Selects correct ICD-10-CM (diagnostic), CPT (procedural) and HCPCS codes based upon interpretation of office visit and other documentation, correct coding principles, and clinical validation with a focus on accurate capture of all supported HCC diagnosis codes. Remains up to date on all coding changes and usage.
  5. Assesses qualifying notes for completion and/or identification of deficiencies; Communicates with provider/staff on elements to be addressed to ensure the note can be processed within the required timeline.
  6. Performs review of Risk Adjustment audits for accuracy and for data entry into the EMR.
  7. Utilizes nursing and coding knowledge to assist with review activities to support the Risk Adjustment process to include re-review of audit findings to ensure accuracy in documented HCC diagnoses and ICD-10 coding; review of various payer denial/rejection reports to identify areas for provider education.
  8. Completes required electronic forms necessary for submission of applicable acuity diagnosis codes based on scheduled appointments.

Education and Training: Minimum high school education or equivalent required. An active Coding Certification by AHIMA (RHIA, RHIT, CCS, CCS-P or CCA) or AAPC (CPC, CRC) is required. Graduation from an approved practical nursing program and state-licensed practical nurse preferred. CPR with AED certification required. All certifications are required as initial and continued employment at Gonzaba Medical Group.
Experience: 3+ years' experience in working with the Risk Adjustment (HCC) process preferred. Knowledge of ICD-10-CM, CPT, and HCPCS coding systems, guidelines, and rules. Knowledge of billing regulations, Managed Care insurance coverage limitations and protocols. Knowledge of medical terminology, medical procedures, human anatomy, and physiology.
Other Requirements: Computer Skills: Skilled in use of computer/EMR systems. Knowledge of Word processing software, spreadsheet software, Internet, and database software.
Work Environment: Depending upon the area assigned, may be 100% clinical setting or office setting in a clinical environment. Exposure to communicable diseases, bodily fluids, toxic substances, ionizing radiation, medicinal preparations, and other conditions common to a clinic environment.
Mental / Physical Requirements: Requires manual dexterity, sitting, standing, stooping, reaching, kneeling, crouching, bending, walking, lifting up to 40 lbs. without assistance. Close vision and ability to adjust focus. Must be able to work efficiently under pressure.
Additional Information: Gonzaba Medical Group is seeking team members who contribute as A-Players, demonstrate a strong work ethic, are committed to the culture and our core values.
Other Duties As Assigned: The above job description is not intended to be an all-inclusive list of duties and standards of the position. Team members will follow any other instructions, and perform any other related duties, as assigned by their supervisor. Responsibilities, knowledge, skills, abilities, and work environments may change as needs evolve

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