Title: Coding Quality Review Auditor - Ambulatory (Remote) Location: Roseville, CA, United States Department: Support Services Job Description: Description Located in the metropolitan area of Sacramento, the Adventist Health corporate headquarters have been based in Roseville, California, for more than 40 years. In 2019, we unveiled our WELL-certified campus - a rejuvenating place for associates systemwide to collaborate, innovate and connect. Adventist Health Roseville and shared service teams have access to enjoy a welcoming space designed to promote well-being and inspire your best work. Job Summary: Performs quality reviews and audits to ensure compliance with DRG validation, ICD-10/PCS, and CPT coding guidelines. Coordinates with department leadership to ensure standards are met in accordance with department and organization policy. Contributes to improving the processes and infrastructure of the department. Demonstrates proficiency in facilitation and interpersonal communication, organizational skills, prioritization of tasks, professionalism, and educating and training as required. Uses in depth understanding of the CQR quality workplan to will promote compliance and awareness of the plan. Acts as a subject matter expert (SME) in national coding guidelines for hospital inpatient, outpatient, and/or Professional fee coding and will ensure compliance with those guidelines along with all company coding policies. Uses performance improvement analyses to improve the accuracy, integrity and quality of patient data, ensure minimal variation in coding practices, and improve the quality of physician documentation within the body of the medical record to support code assignments which results in appropriate reimbursement and data integrity. Job Requirements: Education and Work Experience: - High School Education/GED or equivalent: Required - Associate’s/Technical Degree or equivalent combination of education/related experience: Preferred - Five years' acute care inpatient, outpatient coding experience, and/or professional fee coding: Required - Three years' coding auditing/monitoring experience: Preferred Licenses/Certifications: - Certified Coding Specialist credential (CCS) through AHIMA or AAPC; credential type specific to auditing being performed.: Required Essential Functions: - Performs regularly scheduled quality reviews and audits per departmental policies and procedures (routine, pre-bill, policy driven, targeted, and post-bill) for hospital inpatient, outpatient, and/or professional fee coding. Facilitates the coder audit appeal process, providing rationale and education to the coding team as required. Performs ad hoc quality reviews, such as targeted DRG reviews, and special projects as assigned by management. - Prepares detailed audit reports outlining findings, recommendations, rationale, and corrective actions needed. Facilitates the coder appeal process. Assists team members with coding questions and provide resolution guidance. - Assists in ensuring coding staff adherence with coding guidelines and policy, both internal and vendor teams. Demonstrates and applies expert level knowledge of medical coding practices and concepts. Communicates appropriately with manager and all stakeholders as required. - Identifies and communicates educational opportunities to manager. Maintains working knowledge of workflows, systems, and tools used in the department. Reviews all official data quality standards, coding guidelines, company policies and procedures, and clinical/medical resources to assure coding knowledge and skills remain current. - Maintains up-to-date knowledge of medical terminology, coding guidelines, quality standards, regulatory changes, etc. that affect the audit process. Assists in creation and maintenance of a positive working environment, including effective communication and setting an appropriate professional example. - Performs other job-related duties as assigned. Organizational Requirements: Adventist Health is committed to the safety and wellbeing of our associates and patients. Therefore, we require that all associates receive all required vaccinations as a condition of employment and annually thereafter, where applicable. Medical and religious exemptions may apply. Adventist Health participates in E-Verify. Visit https://adventisthealth.org/careers/everify/ for more information about E-Verify. By choosing to apply, you acknowledge that you have accessed and read the E-Verify Participation and Right to Work notices and understand the contents therein. About Us Adventist Health is a faith-based, nonprofit, integrated health system serving more than 100 communities on the West Coast and Hawaii with over 440 sites of care, including 27 acute care facilities. Founded on Adventist heritage and values, Adventist Health provides care in hospitals, clinics, home care, and hospice agencies in both rural and urban communities. Our compassionate and talented team of more than 38,000 includes employees, physicians, Medical Staff, and volunteers driven in pursuit of one mission: living God's love by inspiring health, wholeness and hope Job Info - Job Identification 63823 - Job CategoryAssociate - Locations ONE Adventist Health Way, Roseville, CA, 95661, US - Job ShiftDay Shift - Pay RangeThe estimated base pay for this position is $36.91 to $50.62. Additional individual compensation may be available for this role through differentials, extra shift incentives, bonuses, etc. Base pay is only a portion of the total rewards package, and a comprehensive benefits program is available for qualifying positions. Please contact our Talent Acquisition team for more information. - Hiring DepartmentRC Coding - Ambulatory - Shift Length8 Hours

Role Description The Quality Auditor will perform routine and targeted operational quality audits across health plan operations including but not limited to Claims, Grievances and Appeals, Enrollment, Configuration, Provider Data and/or Letters/Materials to ensure compliance with regulatory requirements, internal policies, contractual obligations, and operational standards. This role monitors quality, accuracy, and identifies opportunities for improvements that will enhance member and provider experience. - Ensure regulatory compliance and overall quality and efficiency by utilizing strong working knowledge of Claims, Grievances and Appeals, Enrollment, Configuration, Provider Data and/or Letters/Materials standards for assigned business process. - Work assigned cases through SCAN's workflow system, and apply correct status attributes to track and trend issues. Notate cases/audits with required detail to ensure that others understand the status of case/audit and final resolutions. - Work closely with other business units to ensure processing errors are reviewed and corrected. - Follow policies and procedures to maintain efficient and compliant operations; communicate suggestions for improvement and efficiencies to management; identify and report problems with workflows following proper departmental procedures; actively participate in departmental staff meetings and training sessions. - Follow all appropriate Federal and State regulatory requirements and guidelines applicable to SCAN Health Plan operations or as documented in company policies and procedures. - Provide a high level of customer service to internal customers by consistently meeting and/or exceeding team expectations including but not limited to quality, productivity, and attendance. - Escalate appropriate audit issues to management as required and follow departmental/organizational policies and procedures. - Maintain required levels of production and quality standards as established by management. Participate in and support ad-hoc audits as needed. - Contribute to overall department success by participating in department initiatives, effective communication and collaboration with all members of the SCAN team through knowledge and idea sharing, take ownership to identify and report issues to appropriate management staff for resolution and work actively with the SCAN team to improve the support to our Members and Providers. - Contribute to team effort by accomplishing related results as needed. - Actively support the achievement of SCAN’s Vision and Goals. - We seek Rebels who are curious about AI and its power to transform how we operate and serve our members. - Other duties as assigned. Qualifications - Associate’s degree preferred or equivalent experience. - 3+ years complex auditing processing and/or auditing experience in the health plan, healthcare, or managed care organization with experience in Claims, Grievances and Appeals, Enrollment, Configuration, Provider Data and/or Letters/Materials. - Must be proficient in processing/auditing for Medicare and Medicaid plans. - 3+ years’ experience in managed healthcare environment related to Claims, Grievances and Appeals, Enrollment, Configuration, Provider Data and Letters/Materials processing/audit. - Strong organizational, analytical thinking and accounting skills; oral and written communication skills. - Strong knowledge of CMS requirements regarding auditing processing. - Completion of health insurance training and medical terminology or equivalent knowledge through on-the-job training and experience. - Knowledge of health care benefit structures and insurance procedures, as they exist in a Managed Care environment. - Strong PC Skills. Microsoft Office (Word, Excel, Outlook, Teams) are required. Benefits - Base wage range: $25.38 to $36.76 per hour. - Work Mode: Remote. - Annual bonus program. - Robust Wellness Program. - Generous paid-time-off (PTO). - Eleven paid holidays per year, plus 1 additional floating holiday, plus 1 birthday holiday. - Excellent 401(k) Retirement Saving Plan with employer match and contribution. - Robust employee recognition program. - Tuition reimbursement. - An opportunity to become part of a team that makes a difference to our members and our community every day!

Role Description This role owns end-to-end process performance and strategy for the Invoice-to-Cash (I2C) tower, from global process design and standardization through to BPO vendor governance and business stakeholder accountability. The I2C GPL is the single point of accountability for service outcomes, process excellence, and continuous value creation across all geographies; specifically covering billing and invoice distribution, collections, cash application, risk management, and credit management activities. Reports to the VP, Global Business Services and owns the end-to-end operational performance for the I2C tower within GBS. Key Responsibilities - Serve as the primary business-facing partner for assigned functional leaders (CFO, CAO, BU Presidents and finance leaders), owning a formal service cadence that translates business priorities into I2C delivery commitments. - Own escalation accountability for I2C service gaps; ensuring billing disputes, collections issues, and cash application exceptions are surfaced, owned, and resolved without the business having to chase. - Govern the BPO vendor relationship for the I2C tower, including SLA enforcement, performance reviews, and commercial discipline across billing, collections, and cash application. - Lead daily and weekly operating cadence to manage billing runs, collections activity, cash application, and backlog. - Own SLA and KPI performance across I2C including billing delivery, days sales outstanding (DSO), collection effectiveness index (CEI), and cash application rates. - Forecast demand trends and align vendor staffing and capacity plans accordingly. - Ensure execution and documentation of process controls and audit requirements across I2C activities. - Maintain exception management framework aligned to policy and governance standards. - Build and prioritize continuous improvement pipeline including automation and simplification within the I2C tower. - Partner with Process Excellence and Digital teams to deliver measurable productivity gains across billing, collections, and cash applications. Qualifications - Acts as the voice of the business inside GBS; owning the I2C service relationship with BU leaders and ensuring delivery is always aligned to business outcomes, not just operational metrics. - Proven track record of earning the trust of business unit CFOs and functional leaders by consistently prioritizing their operational needs within the I2C delivery model. - Familiarity with the upstream order management and customer service processes that feed I2C; with the ability to partner across tower boundaries to resolve systemic handoff issues. - Strong operational leadership with deep understanding of I2C processes; including billing and invoicing, credit management, collections, risk management, and cash application. - Expertise in I2C KPI management (DSO, CEI, billing delivery accuracy, cash application rates), root cause analysis, and structured escalation frameworks. - Experience managing outsourced or hybrid retained-vendor delivery models within an I2C or receivables context. - Capacity planning and workforce optimization capability across geographies. - Experience managing outsourced service providers in SLA-based environments. - Demonstrated experience leading or partnering on automation, AI-enabled workflow, or intelligent process redesign initiatives within a GBS or shared services environment. - Demonstrated track record of driving year-on-year productivity improvement. - High attention to detail with strong financial and commercial acumen. - Cross-functional coordination across functional groups and customer teams. - Exceptional analytical, organizational, and resource-planning abilities. - Demonstrated initiative, autonomy, and creativity in problem-solving. - Proven ability to manage multiple tasks and prioritize and execute effectively. - Excellent oral and written communication skills for effective collaboration. - Strong interpersonal skills, fostering collaborative teamwork across disciplines. - Strong planning discipline with excellent conceptual and organizational skills. General Skills & Competencies - Outstanding management and leadership skills and ability to attract, retain, motivate, develop, mentor and coach team members for high performance; good conceptual skills. - Outstanding verbal and written communication skills and ability to resolve disputes effectively and efficiently. - Outstanding presentation and public speaking skills. - Mastery independent decision making, analysis and problem-solving skills. - Understand, interpret and act on financial information and external trends that contribute to business profitability. - Plan, manage and create strategy around complex projects; understand available resources, develop timeline, budget and assign areas of responsibility. - Lead teams to achieve company goals and solve complex business issues in creative and effective ways. - Mastery planning and organizational skills and techniques. - Communicate effectively with senior management and key stakeholders. - Excellent negotiating skills and ability to effectively manage strategic alliances, joint ventures and outsourced relationships. - Ability to influence, build relationships, understand organizational complexities, manage conflict and navigate politics. - Broad professional and managerial skills with a full understanding of industry practices and company policies and procedures. - Lead and develop virtual teams. - Mastery in multiple technical and business skills. - Excellent strategic planning skills. Minimum Work Experience - Typically, 12 or more years of professional experience of increasing responsibility and complexity in Finance operations, order-to-cash, or shared services leadership roles; 7 or more years of management experience. Preferred Education - Typically, a Bachelor's Degree or global equivalent in Finance, Accounting, or a related discipline. Master's degree or global equivalent is preferred. Travel / Physical Demands - Travel typically less than 20%. Office environment. No special physical demands required. Compensation & Benefits - The posted range for this position is $184,000 - $263,000 which is the expected starting base salary range for an employee who is new to the role to fully proficient in the role. Many factors go into determining employee pay within the posted range including education, prior experience, training, current skills, certifications, location/labor market, internal equity, etc. - This position is eligible for a bonus not reflected in the posted range. - Other benefits available include: - Medical, Dental and Vision Coverage - 401K Plan with Company Match - PTO [or sick leave if applicable] - Paid Parental Leave - Income Protection - Work Life Assistance Program - Flexible Spending Accounts - Educational Benefits - Worldwide Scholarship Program - Volunteer Opportunities

Role Description The Risk Adjustment Coding Auditor reviews medical records to ensure accurate, compliant ICD 10 CM coding across Medicare Advantage, ACA/Commercial, and Medicaid programs. This role validates coding accuracy and specificity, audits external coding vendors, and provides feedback to improve documentation and coding performance. The auditor also leads ACA and Medicare Advantage RADV activities, ensuring timely retrieval, review, and submission of records in line with federal and state requirements. - Conduct retrospective and prospective medical record audits to ensure ICD 10 CM diagnosis codes are accurate, complete, specific, and supported by documentation. - Ensure all coding practices comply with CMS risk adjustment guidelines, ICD 10 CM Official Coding Guidelines, and AAPC/AHIMA standards. - Identify coding trends, documentation gaps, errors, and opportunities to improve risk score accuracy. - Validate clinical evidence supporting chronic condition coding to ensure proper documentation and submission. - Prepare detailed audit reports summarizing findings, error categories, trends, and recommendations for corrective action. - Provide clear, constructive feedback to coding teams, providers, and vendor partners based on audit outcomes. - Develop and deliver training materials, job aids, and educational sessions to address documentation and coding improvement areas. - Serve as a subject matter expert on risk adjustment coding best practices, documentation requirements, and regulatory updates. - Collaborate with internal teams including Risk Adjustment Operations, Coding, Compliance, Quality, and Provider Engagement. - Lead and execute ACA and Medicare Advantage RADV audits, including medical record retrieval, coding review, appeals support, and documentation submission to IVA and CMS portals. - Oversee coding vendors and In Home Assessment programs to ensure performance aligns with contractual SLAs. - Obtain medical records from provider Electronic Health Record (EHR) systems and coordinate remote EHR access for internal teams and chart review vendors. - Maintain audit documentation and support tracking of corrective action plans. - Participate in internal and external audits initiated by regulatory bodies, partners, or compliance teams. - Support the development and refinement of audit methodologies, tools, and internal risk adjustment processes. - Assist in updating organizational policies and procedures to ensure regulatory compliance. - Monitor changes in risk adjustment regulations and coding guidelines and incorporate required updates into internal practices. Qualifications - A minimum of 4 years of risk adjustment coding experience, including hands-on HCC coding, is required. - Proficiency in coding directly from the ICD 10 CM code book is required. - Experience with different EMRs and medical records retrieval outreach activities is required. - Experience conducting coding audits and interpreting complex regulatory guidelines is highly preferred. - Prior experience working within a health insurance plan, health system, or large provider organization is preferred. - Experience developing or delivering coder or provider education is also desirable. Requirements - Bachelor’s degree preferred. - High school diploma or equivalent required. - Active Certified Risk Adjustment Coder (CRC) and Certified Professional Medical Auditor (CPMA) certifications through AAPC are required. Benefits - Base Range: $72,443.87 - $126,776.77 Environment - Work inside in a general office setting with ergonomically configured equipment. - Travel is required approximately 5% of the time. Skills - Accountability - Collaboration - Communication (written/verbal) - Flexibility - Listening (active) - Organizational skills/Planning and Organization - Problem Solving - Teamwork Physical Requirements - Stoop and bend. - Sit and/or stand for extended periods of time while performing core job functions. - Repetitive motions to include typing, sorting, and filing. - Light lifting and carrying of files and business materials. - Ability to read and comprehend both written and spoken English. - Communicate clearly and effectively. Disclaimer This job description indicates the general nature and level of work performed by employees within this position and is subject to change. It is not designed to contain or be interpreted as a comprehensive list of all duties, responsibilities, and qualifications required of employees assigned to this position. Employment remains AT-WILL at all times.