Data Quality Auditor, Analyst

This is a fully remote position, open to applicants in Alabama, +5 more states.

📋 Description

• Conduct quality audits of medical records coded by internal teams to ensure inter-rater reliability.

• Verify that ICD-10 codes submitted to CMS for risk adjustment are appropriate, accurate, and substantiated by clinical documentation.

• Provide support for coding decisions and judgments using recognized industry evidence and tools.

• Relay audit findings to clinical and coding personnel, federal regulators, and vendor coding resources.

• Facilitate dispute resolution processes.

• Mentor and educate internal staff based on audit outcomes, including general education on ICD coding.

• Present audit processes and outcomes to various departments and management.

• Execute process audits to ensure compliance with internal policies, procedures, and regulatory guidelines from CMS, OIG, and others.

• Identify and suggest improvements to processes to enhance productivity, quality, efficiency, and accuracy.

• Collaborate across functions to share best practices.

• Adhere to project deadlines while maintaining coding accuracy and production standards.

• Monitor personal work quality to ensure high standards.

• Uphold ethical standards while managing patient data in accordance with HIPAA requirements.

• Act as a training resource and subject matter expert for vendors, providers, and team members on ICD coding and documentation standards.

• Accurately assign diagnosis codes based on documentation from physicians and qualified healthcare providers.

• Identify and report documentation deficiencies for the education of providers, vendors, and peers.

• Perform additional related duties as assigned.

⛳️ Requirements

• Proficiency in computer applications, including Microsoft Office Suite (Word, Excel, Access, PowerPoint, Outlook) and standard coding software.

• Experience with International Classification of Disease (ICD) codes.

• At least 5 years of recent and relevant experience in medical record documentation review, diagnosis coding, and/or auditing.

• Familiarity with the Medicare and/or Commercial and/or Medicaid Risk Adjustment processes and Hierarchical Condition Categories (HCC).

• Required certifications include CPC (Certified Professional Coder) or CCS-P (Certified Coding Specialist-Physician) and CRC (Certified Risk Adjustment Coder).

• Preferred certifications include CPMA, CDEO, or CPC-I.

• Strong analytical and problem-solving capabilities.

• Excellent communication, organizational, and interpersonal skills.

• A BA/BS degree or equivalent professional experience.

• Completion of the AAPC/AHIMA training program for core credentials (CPC, CCS-P) along with work history or on-the-job experience equivalent to approximately 3 years for CPC.

• 5–8 years of additional credentials and/or application of credentials.

• Knowledgeable in ICD coding and CMS documentation requirements, as well as State and Federal regulations.

• Proficient in medical record auditing and abstraction techniques.

• Understanding of medical terminology and anatomy for all body systems.

• Familiarity with risk adjustment auditing processes.

• Awareness of medical documentation, fraud, abuse, and penalties associated with documentation and coding violations.

• Ability to apply AHA Coding Clinic guidance effectively.

• Capability to manage patient data in accordance with HIPAA Privacy and Security regulations.

🏝️ Benefits

• CVS Health bonus, commission, or short-term incentive program in addition to the base salary range.

• Medical insurance coverage.

• Dental insurance coverage.

• Vision insurance coverage.

• Paid time off.

• Retirement savings plans.

• Wellness initiatives.

• Additional resources promoting physical, emotional, and financial well-being, depending on eligibility.