Coding Data Quality Auditor Analyst

CVS Health•Indianapolis, IN

1d•$21 - $45

About The Position

Responsible for performing quality inter-rater review audits of medical records coded by 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. In this position you will have the opportunity to demonstrate proficiency in the following: Proven ability to support coding judgment and decisions using industry standard evidence and tools. Ability to 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. Leads dispute resolution. Acts as mentor to provide education to internal staff based on audit findings; provides general education on ICD codes as appropriate. Effectively communicates the audit process and results to appropriate departments and management. Conducts process audits to ensure compliance with internal policies and procedures and existing CMS regulations. Identifies and recommends opportunities for process improvements so that productivity and quality goals can be met or exceeded and operational efficiency and final accuracy is achieved. Ability to 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. Must possess high level of dependability and is able to meet coding accuracy and production standards. Monitors own work to help ensure quality. Required to 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. Possesses a genuine interest in improving and promoting quality; demonstrates accuracy and thoroughness and assists others to achieve the same through mentoring and instruction. Medical record auditing skills and abstraction expertise. Serves as the training resource and subject matter expert to vendors, providers and other team members for questions regarding ICD coding and documentation requirements. Conducts process audits to ensure compliance with internal policies and procedures as well as regulatory guidance from CMS, OIG or other Regulatory body. Expertise in assigning accurate medical codes for diagnoses as documented for physicians and other qualified healthcare providers in the office and/or facility setting. Thorough knowledge of coding guidelines and regulations to meet compliance requirements, such as establishing medical necessity. 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. 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. Remains current on educational training and requirements including ICD coding, CMS documentation requirements, and State and Federal regulations. Performs other related duties as required

Requirements

Computer proficiency including experience with Microsoft Office products (Word, Excel, Access, PowerPoint, Outlook, industry standard coding applications)
Experience with International Classification of Disease (ICD) codes required
Minimum of 5 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
CPC (Certified Professional Coder) or CCS-P (Certified Coding Specialist-Physician) and CRC (Certified Risk Adjustment Coder) required
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
5-8 years encompassing additional credentials and/or application of credentials

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

Performing quality inter-rater review audits of medical records coded by internal team (CDQA and Sr CDQA)
Ensuring ICD-10 codes submitted to CMS for risk adjustment are appropriate, accurate, and supported by clinical documentation
Supporting coding judgment and decisions using industry standard evidence and tools
Communicating evidence across stakeholders with varying knowledge and clinical expertise
Leading dispute resolution
Mentoring and educating internal staff based on audit findings
Communicating the audit process and results to appropriate departments and management
Conducting process audits to ensure compliance with internal policies and procedures and existing CMS regulations
Identifying and recommending opportunities for process improvements
Working independently and collaboratively within cross-functional teams
Adhering to stringent timelines
Meeting coding accuracy and production standards
Monitoring own work to ensure quality
Handling patient data ethically and in compliance with HIPAA's Privacy and Security rules
Serving as a training resource and subject matter expert to vendors, providers, and other team members
Assigning accurate medical codes for diagnoses
Identifying and communicating documentation deficiencies
Applying AHA Coding Clinic guidance to identify and resolve coding issues
Remaining current on educational training and requirements including ICD coding, CMS documentation requirements, and State and Federal regulations