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Sanford Health Data Validation & Risk Adjustment Specialist in Sioux Falls, South Dakota

Sanford Health is one of the largest and fastest-growing not-for-profit health systems in the United States. We're proud to offer many development and advancement opportunities to our nearly 50,000 members of the Sanford Family who are dedicated to the work of health and healing across our broad footprint.

See yourself at Sanford!

Facility: Cherapa Place Building
Location: Sioux Falls, SD
Address: 300 N Cherapa Pl, Sioux Falls, SD 57103, USA
Shift: 8 Hours - Day Shifts
Job Schedule: Full time
Weekly Hours: 40.00

Job Summary

This position assures the Risk Adjustment Data Validation (RADV) requirements outlined by CMS are followed for each client project. This position uses clinical coding knowledge of documentation requirements to assure the quality and completeness of clinical documentation for risk adjustment audits on a retrospective basis. The position uses critical thinking, problem solving and analytic skills to assure the quality and completeness to perform expectations outlined by CMS in regards to Health Plan member enrollment audit validation, Health Plan member claim adjudication audit validation and medical record quality and completeness for member health status validation. Work collaboration with internal and external customers are essential to each project. Documented results are tracked and trend in various audit tools and applications. Duties include but not limited to: validating and abstracting diagnosis codes from provider documentation, entering essential information into a data base; follow the official coding guidelines including AHA Coding Clinic and other similar authoritative resources; regularly and consistently meets quality and productivity standards established by management; participate in Quality Assurance program and follow up training; and partnering with sub-contractors to fulfill Health Plan responsibilities.

Analyze medical record audit (MRA) data to identify patterns and development of interventions at the provider and market level to coordinate an educational work plan for contracted providers. Conduct provider education and training regarding risk adjustment to help to ensure accurate CMS payment and to improve quality of care. This includes training venues such as provider offices, hospitals, webinars, conference calls, email correspondence, etc.

Complete administrative tasks in a timely manner and in accordance with management expectations, such as time reporting/keeping and maintain productivity standards. Work in conjunction with other departments to include Provider Relations, Quality as well as the Medical Director for the state assigned to ensure compliance of CMS risk adjustments guidelines are met. Subject matter experts for proper risk adjustment coding and CMS data validation. Works on additional risk adjustment audit requests (i.e. outside auditors' requests). Maintain ongoing communication with management regarding project workload, turnaround time expectations and deliverables. Independently monitors changes in law, regulations, rules, and code assignment that impacts documentation and Risk Adjustment.

Department Details

Join a growing area of Sanford Health Plan that works to improve the product and insurance offerings to our members!


High school diploma or GED required. Associates or bachelor’s degree in Health Information or other relevant field of study preferred.

Two years experience in coding with knowledge of Medicare risk adjustment (HCC coding) required. OR

Five years experience as a medical coder (ICD 9 & ICD 10), CPT, E/M, HCC etc.) in an acute care setting with multiple specialty disciplines required.

American Health Information Management (AHIMA) Certified Coding Specialist (CCS) or American Academy of Professional Coder (AAPC) Certified Professional Coder (CPC) or Certified Professional Coder Hospital (CPC-H) Coding Certification required.

Registered Health Information Administrator (RHIA) or Registered Health Information Technician (RHIT) preferred.

Active nursing license preferred (Registered Nurse or Licensed Practical Nurse);


Sanford Health offers an attractive benefits package for qualifying full-time and part-time employees. Depending on eligibility, a variety of benefits include health insurance, dental insurance, vision insurance, life insurance, a 401(k) retirement plan, work/life balance benefits, sick leave and paid time off. To review your benefit eligibility, visit .

Sanford is an EEO/AA Employer M/F/Disability/Vet. If you are an individual with a disability and would like to request an accommodation for help with your online application, please call 1-877-673-0854 or send an email to .

Sanford Health has a Drug Free Workplace Policy. An accepted offer will require a drug screen and pre-employment background screening as a condition of employment.

Job Function: Health Plan
Req Number: R-35771
Featured: No