Quality Review and Audit Analyst

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

📋 Description

• Perform medical record evaluations and accurately extract diagnosis codes in accordance with relevant coding guidelines, Cigna standards, HHS protocols, and other regulations.

• Utilize HHS’ Risk Adjustment Model to verify the correctness of HCCs derived from ICD-10-CM diagnosis codes for the appropriate Benefit Year.

• Employ longitudinal thinking to pinpoint valid data elements and identify opportunities for data collection.

• Conduct documentation and data audits to detect gaps, inaccuracies, and compliance risks within risk adjustment data.

• Assist with IFP Risk Adjustment initiatives, including RADV audits and the Supplement Diagnosis submission program.

• Carry out quality audits for vendor coding partners.

• Collaborate with team members and matrix partners to provide education on coding and Risk Adjustment.

• Coordinate with stakeholders to implement efficient and compliant Risk Adjustment programs.

• Promptly escalate identified risks and program deficiencies to management.

• Effectively communicate with all audiences both verbally and in writing.

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

• Contribute to updates of Cigna IFP Coding Guidelines and policy decisions as necessary.

⛳️ Requirements

• High school diploma.

• Over 2 years of experience in one of the specified coding certifications/credentials.

• Current coding certification from AHIMA or AAPC: CPC, CCS-P, CCS-H, RHIT, or RHIA.

• CRC certification; those with another listed certification must obtain CRC certification within six months of hire.

• Experience with medical documentation audits and medical chart reviews.

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

• Familiar with CMS regulations related to Risk Adjustment programs and documentation and coding compliance policies.

• Experience in both inpatient and outpatient documentation.

• Preferred experience in HCC coding.

• Competent in using Excel, MS Word, and Adobe Acrobat.

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

• Understanding of medical claims submissions is preferred.

• Ability to meet deadlines, productivity, and accuracy standards.

• If working remotely, must have access to cable broadband or fiber optic internet with a minimum of 10Mbps download/5Mbps upload.

🏝️ Benefits

• Eligibility for an annual bonus plan.

• Medical benefits.

• Vision benefits.

• Dental benefits.

• Well-being and behavioral health programs.

• 401(k) plan.

• Company-paid life insurance.

• Tuition reimbursement.

• A minimum of 18 days of paid time off per year.

• Paid holidays.

• Leaves of absence.

• Cable broadband or fiber optic internet service with speeds of at least 10Mbps download/5Mbps upload for remote work.