Coding Data Quality Auditor, Analyst

CVS Health

23h

About The Position

We’re building a world of health around every individual — shaping a more connected, convenient and compassionate health experience. At CVS Health®, you’ll be surrounded by passionate colleagues who care deeply, innovate with purpose, hold ourselves accountable and prioritize safety and quality in everything we do. Join us and be part of something bigger – helping to simplify health care one person, one family and one community at a time. This position is responsible for performing quality inter-rater review audits of medical records coded by an internal team (CDQA and Sr CDQA) to ensure the ICD-10 codes that are submitted to the Centers for Medicare and Medicaid Services (CMS) for the purpose of risk adjustment processes are appropriate, accurate, and supported by clinical documentation in accordance with all State and Federal regulations and internal policies and procedures.

Requirements

CPC (Certified Professional Coder) or CCS-P (Certified Coding Specialist-Physician) and CRC (Certified Risk Adjustment Coder) required.
Experience with International Classification of Disease (ICD) codes required.
Minimum of 3 years recent and related experience in medical record documentation review, diagnosis coding, and/or auditing.
Experience with Medicare and/or Commercial and/or Medicaid Risk Adjustment process and Hierarchical Condition Categories (HCC) required.
Computer proficiency including experience with Microsoft Office products (Word, Excel, Access, PowerPoint, Outlook, industry standard coding applications).
BA/BS or equivalent experience.
Completion of AAPC/AHIMA training program for core credential (CPC, CCS-P) with associated work history/on the job experience equal to approximately 3 years for CPC.

Nice To Haves

CPMA (Certified Professional Medical Auditor), CDEO (Certified Documentation Expert Outpatient) or CPC-I (Certified Professional Coding Instructor) preferred.
Excellent analytical and problem solving skills.
Superior communication, organizational, and interpersonal skills.

Responsibilities

Support coding judgment and decisions using industry standard evidence and tools.
Confidently speak to such evidence across stakeholders with varying knowledge and clinical expertise in either written or verbal forms including communication with clinical or coding staff, federal regulators and vendor coding resources.
Lead dispute resolution.
Act as mentor to provide education to internal staff based on audit findings; provide general education on ICD codes as appropriate.
Effectively communicate the audit process and results to appropriate departments and management.
Conduct process audits to ensure compliance with internal policies and procedures and existing CMS regulations.
Identify and recommend opportunities for process improvements so that productivity and quality goals can be met or exceeded and operational efficiency and final accuracy is achieved.
Work independently as well as in a cross functional role within other teams for collaboration on best practices.
Adhere to stringent timelines consistent with project deadlines and directives.
Possess high level of dependability and be able to meet coding accuracy and production standards.
Monitor own work to help ensure quality.
Act in ethical manner at all times as required under HIPAA's Privacy and Security rules to handle patient data with uncompromised adherence to the law.
Possess a genuine interest in improving and promoting quality; demonstrate accuracy and thoroughness and assist others to achieve the same through mentoring and instruction.
Perform medical record auditing and abstraction expertise.
Serve as the training resource and subject matter expert to vendors, providers and other team members for questions regarding ICD coding and documentation requirements.
Conduct process audits to ensure compliance with internal policies and procedures as well as regulatory guidance from CMS, OIG or other Regulatory body.
Assign accurate medical codes for diagnoses as documented for physicians and other qualified healthcare providers in the office and/or facility setting.
Apply thorough knowledge of coding guidelines and regulations to meet compliance requirements, such as establishing medical necessity.
Apply in-depth knowledge of medical terminology and anatomy for all body systems.
Understand the audit process for risk adjustment models.
Identify and communicate documentation deficiencies to allow for continuous education opportunities for providers, vendors and peers.
Apply expertise in medical documentation, fraud, abuse and penalties for documentation and coding violations based on governmental guidelines.
Apply AHA Coding Clinic guidance to identify and resolve coding issues.
Remain current on educational training and requirements including ICD coding, CMS documentation requirements, and State and Federal regulations.
Perform other related duties as required.