Job Description

Job Description Summary

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The Burden of Illness Prospective Quality Assurance Educator is responsible for auditing, training, and supporting the prospective BOI risk adjustment team that performs pre-visit chart reviews to identify and surface Hierarchical Condition Category (HCC) conditions for provider assessment and documentation. This role ensures compliance with CMS and HHS risk adjustment guidelines, ICD-10-CM coding standards, and organizational policies while building staff competency through education, feedback, and quality improvement initiatives.

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How will you make an impact & Requirements

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Audit & Validation Oversight

• Perform internal audits of prospective chart reviews to validate clinical evidence, HCC capture, and correct ICD-10-CM code selection.
• Evaluate accuracy, completeness, and compliance of clinical evidence suspecting workflows.
• Identify trends, gaps, and risk areas; develop corrective action plans and internal education strategies.
• Monitor regulatory updates (CMS, HHS, ICD-10, HCC model changes) and integrate them into audit criteria.

Education & Coder Development

• Develop and deliver onboarding and ongoing education for prospective risk adjustment coding staff.
• Create training materials, tip sheets, job aids, and reference tools.
• Provide one-on-one and group feedback sessions based on audit results.
• Onboard and mentor new coding staff.

Quality Improvement

• Serve as subject matter expert for HCC coding, ICD-10-CM guidelines, and CMS and HHS risk adjustment rules.
• Participate in policy and procedure development related to risk adjustment and documentation standards.
• Collaborate with coding leadership, BOI department teams, and provider education team.

Qualifications

Required

• Active credential: CRC, CPC, CPMA, or similar certification
• 3–5+ years of risk adjustment coding and/or auditing experience
• Strong knowledge of CMS-HCC models, ICD-10-CM, MEAT, and audit methodology
• Experience providing education or training to internal coding teams
• Excellent written and verbal communication skills
• Strong analytical and reporting skills
• Ability to work independently in a fast-paced, cross-functional environment

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Compensation Range:

$58,165.00

to

$87,247.00

The anticipated base salary range represents the Company's good-faith estimate of the compensation it reasonably expects to pay for this position at the time of posting. Actual compensation will be determined based on factors including experience, skills, qualifications, geographic location, internal equity, and business needs.