Quality Review and Audit Analyst

This is a fully remote position, open to applicants in Tennessee.

📋 Description

• Perform reviews of medical records and accurately extract diagnosis codes in accordance with Official Coding Guidelines and Conventions, Cigna IFP Coding Guidelines and Best Practices, HHS protocols, and other relevant regulations.

• Utilize the HHS Risk Adjustment Model to verify Hierarchical Condition Categories identified from abstracted ICD-10-CM diagnosis codes for the appropriate Benefit Year.

• Employ longitudinal thinking to pinpoint valid data elements and opportunities for data capture under HHS Risk Adjustment.

• Execute documentation and data audits to uncover gaps, inaccuracies, and compliance risks within IFP Risk Adjustment programs.

• Assist in the Risk Adjustment Data Validation (RADV) audit and the Supplement Diagnosis submission initiative.

• Conduct quality assessments of vendor coding partners.

• Collaborate with team members and matrix partners to provide coding and Risk Adjustment education for both internal and external stakeholders.

• Coordinate with stakeholders to implement effective and compliant Risk Adjustment programs, escalating risks or program gaps to management.

• Communicate effectively to diverse verbal and written audiences.

• Develop and establish internal program processes to ensure compliance with CMS/HHS regulations.

• Contribute to updates of Cigna IFP Coding Guidelines and policy determinations as required.

⛳️ Requirements

• High school diploma.

• Preferred 2 years of experience in one of the specified AHIMA or AAPC coding certifications.

• Certification as CPC, CCS-P, CCS-H, RHIT, RHIA, or CRC; individuals holding a non-CRC certification must obtain CRC certification within 6 months of hire.

• Experience with medical documentation audits and reviews of medical charts.

• Proficiency in ICD-10-CM coding guidelines and conventions.

• Familiarity with CMS regulations regarding Risk Adjustment programs and documentation and coding compliance policies for both inpatient and outpatient documentation.

• HCC coding experience is preferred.

• Computer skills in Excel, MS Word, and Adobe Acrobat.

• Detail-oriented, self-driven, and highly organized.

• Understanding of medical claims submissions is preferred.

• Capability to meet timelines, productivity, and accuracy objectives.

• Home internet connection through a cable broadband or fiber optic provider with a minimum of 10Mbps download and 5Mbps upload speed if working from home.

• Qualified applicants will be considered without regard to legally protected characteristics.

• Qualified applicants with criminal histories will be considered in accordance with applicable federal, state, and local regulations.

🏝️ Benefits

• Remote work arrangement.

• Requirement/support for work-at-home internet service through cable broadband or fiber optic connection with at least 10Mbps download and 5Mbps upload speed.

• Tobacco-free policy (this is a policy/condition of employment rather than an employee benefit).