Coding Data Quality Audit Analyst

CVS Health•Work At Home-Georgia, NV

2d•$21 - $45

About The Position

The Coding Data Quality Audit Analyst performs second-level quality inter-rater review audits of medical records coded by internal teams and, if applicable, external vendors. The role ensures that ICD codes submitted to the Centers for Medicare & Medicaid Services (CMS) for risk adjustment are appropriate, accurate, and supported by clinical documentation, in accordance with state and federal regulations and internal policies and procedures. The analyst supports coding judgments with industry-standard evidence and tools, communicates audit evidence to stakeholders with varying levels of coding and clinical expertise, and mentors internal staff through education based on audit findings. The role also conducts process audits, identifies documentation deficiencies, maintains knowledge of coding and documentation requirements and related regulations, and contributes to quality improvement while working independently and collaboratively and meeting project deadlines.

Requirements

CPC (Certified Professional Coder) or CCS-P (Certified Coding Specialist-Physician) certification required.
At least 3 years of recent, related experience in medical record documentation review, diagnosis coding, and/or auditing.
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.

Nice To Haves

Associate degree or equivalent experience preferred.
CRC (Certified Risk Adjustment Coder) required within the first six months.

Responsibilities

Perform second-level quality inter-rater review audits of medical records coded by internal teams and, if applicable, external vendors.
Support coding judgments and decisions using industry-standard evidence and tools.
Communicate supporting evidence in writing and verbally to internal stakeholders, clinical staff, coding staff, federal regulators, and vendor coding resources.
Mentor and educate internal staff based on audit findings and provide general ICD coding education as appropriate.
Conduct process audits for compliance with internal policies and procedures, CMS regulations, and guidance from the Office of Inspector General (OIG) and other regulatory bodies.
Work independently and collaboratively across cross-functional teams to promote best practices.
Meet stringent timelines and project deadlines.
Support quality improvement, accuracy, and thoroughness and assist others through mentorship and instruction.
Maintain knowledge of coding guidelines and regulations, including requirements for establishing medical necessity.
Identify and communicate documentation deficiencies to support peer education and development.
Maintain knowledge of medical documentation requirements, fraud and abuse regulations, and penalties related to documentation and coding violations under governmental guidelines.