Analyst, Coding Data Quality Audit

CVS Health•New York, NV

3d•$21 - $37

About The Position

The Coding Data Quality Audit Analyst is responsible for performing second-level quality inter-rater review audits of medical records coded by internal teams, as well as external vendors (if applicable), to ensure that ICD codes submitted to the Centers for Medicare & Medicaid Services (CMS) for risk adjustment purposes are appropriate, accurate, and supported by clinical documentation in accordance with all state and federal regulations, as well as internal policies and procedures.

Requirements

Minimum of 3 years of recent, related experience in medical record documentation review, diagnosis coding, and/or auditing.
Associate degree (AA/AS) or equivalent experience.
Completion of an AAPC or AHIMA training program for a core credential (CPC or CCS-P), with associated work history and on-the-job experience equivalent to approximately 3 years for CPC certification.
CPC (Certified Professional Coder) or CCS-P (Certified Coding Specialist-Physician) certification required.

Nice To Haves

CRC (Certified Risk Adjustment Coder) certification required within the first six months.

Responsibilities

Demonstrates the ability to support coding judgments and decisions using industry-standard evidence and tools.
Confidently communicates supporting evidence to internal stakeholders with varying levels of coding and clinical expertise through both written and verbal communication, including interactions with clinical staff, coding staff, federal regulators, and vendor coding resources.
Acts as a mentor by providing education to internal staff based on audit findings and offers general education on ICD coding, as appropriate.
Conducts process audits to ensure compliance with internal policies, procedures, CMS regulations, and guidance from the Office of Inspector General (OIG) and other regulatory bodies.
Demonstrates the ability to work independently and collaboratively across cross-functional teams to promote best practices.
Adheres to stringent timelines and project deadlines.
Demonstrates a genuine commitment to quality improvement, accuracy, and thoroughness while assisting others in achieving the same through mentorship and instruction.
Maintains thorough knowledge of coding guidelines and regulations to ensure compliance requirements are met, including the establishment of medical necessity.
Identifies and communicates documentation deficiencies to support ongoing education and development opportunities for peers.
Maintains extensive knowledge of medical documentation requirements, fraud and abuse regulations, and penalties associated with documentation and coding violations based on governmental guidelines.