Coding Data Quality Auditor

CVS Health

1d•Remote

About The Position

Responsible for performing audit and abstraction of medical records (provider and/or vendor) to identify and submit ICD 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. Proven ability to support coding judgment and decisions using industry standard evidence and tools. Proficient in abstraction and assignment of accurate medical codes for diagnoses as documented by physicians and other qualified healthcare providers in the office and/or facility setting. Sound knowledge of coding guidelines and regulations to meet compliance requirements, such as establishing medical necessity. Identify clinically active vs. historical conditions. Diagnosis codes must be appropriate, accurate, and supported by clinical documentation in accordance with all State and Federal regulations and internal policies and procedures. Utilize medical records to ensure support is documented for etiology and manifestations of disease processes. Adhere to stringent timelines consistent with project deadlines and directives. Conducts self- process audits to ensure compliance with internal policies and procedures as well as regulatory guidance from CMS, OIG or other Regulatory body. 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. In depth knowledge of medical terminology and anatomy for all body systems.-Understand the audit process for risk adjustment models. Performs other related duties as required.

Requirements

CPC (Certified Professional Coder) or CCS-P (Certified Coding Specialist-Physician)
Computer proficiency including experience with Microsoft Office products (Word, Excel, Access, PowerPoint, Outlook, industry standard coding applications).
Capable of making outbound phone calls and faxes to providers for record retrieval and provider communications regarding audits.
Experience with International Classification of Disease (ICD) codes required.
Minimum of 1 year recent and related experience in medical record documentation review, diagnosis coding, and/or auditing.
AA/AS 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 1-2 years for CPC.
CPC (Certified Professional Coder) or CCS-P (Certified Coding Specialist-Physician) required.

Nice To Haves

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
CRC (HCC)
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

Perform audit and abstraction of medical records (provider and/or vendor) to identify and submit ICD codes for risk adjustment processes.
Ensure ICD codes submitted to CMS are appropriate, accurate, and supported by clinical documentation.
Support coding judgment and decisions using industry standard evidence and tools.
Abstract and assign accurate medical codes for diagnoses as documented by physicians and other qualified healthcare providers.
Apply knowledge of coding guidelines and regulations to meet compliance requirements, including establishing medical necessity.
Identify clinically active vs. historical conditions.
Ensure diagnosis codes are appropriate, accurate, and supported by clinical documentation.
Utilize medical records to ensure support is documented for etiology and manifestations of disease processes.
Adhere to stringent timelines consistent with project deadlines and directives.
Conduct self-process audits to ensure compliance with internal policies and procedures and regulatory guidance.
Handle patient data ethically and in compliance with HIPAA's Privacy and Security rules.
Understand the audit process for risk adjustment models.