Coding Data Quality Auditor

CVS Health•Work At Home-Missouri, VT

2d•$19 - $35

About The Position

The Coding Data Quality Auditor performs audits and abstraction of provider and/or vendor medical records to determine whether ICD codes submitted to the Centers for Medicare and Medicaid Services (CMS) for risk adjustment are appropriate, accurate, and supported by clinical documentation, applicable regulations, and internal policies. The role uses industry-standard evidence and tools to support coding judgments and decisions, and abstracts and assigns diagnosis codes documented by physicians and other qualified healthcare providers in office and/or facility settings. The auditor applies coding guidelines and regulations to meet compliance requirements, including establishing medical necessity; distinguishes clinically active from historical conditions; and verifies documentation supporting disease etiology and manifestations. The role also adheres to project timelines and performs self-process audits to check compliance with internal policies and guidance from CMS, OIG, and other regulatory bodies.

Requirements

Minimum of 1 year of recent, related experience in medical record documentation review, diagnosis coding, and/or auditing.
CPC (Certified Professional Coder) or CCS-P (Certified Coding Specialist-Physician) certification.
Computer proficiency, including experience with Microsoft Office products (Word, Excel, Access, PowerPoint, and Outlook) and industry-standard coding applications.
Experience with International Classification of Disease (ICD) codes.
AA/AS degree or equivalent experience.
Completion of an AAPC/AHIMA training program for a core credential (CPC or CCS-P), with associated work history/on-the-job experience equal to approximately 1–2 years for CPC.

Nice To Haves

CRC (Certified Risk Adjustment Coder) certification.
Experience with Medicare, Commercial, and/or Medicaid risk adjustment processes and Hierarchical Condition Categories (HCC).

Responsibilities

Audit and abstract provider and/or vendor medical records.
Determine whether ICD codes submitted to CMS for risk adjustment are appropriate, accurate, and supported by clinical documentation.
Use industry-standard evidence and tools to support coding judgments and decisions.
Abstract and assign accurate diagnosis codes documented by physicians and other qualified healthcare providers in office and/or facility settings.
Apply coding guidelines and regulations to meet compliance requirements, including establishing medical necessity.
Identify clinically active versus historical conditions.
Verify that medical records support the etiology and manifestations of disease processes.
Meet project timelines and directives.
Conduct self-process audits to ensure compliance with internal policies, procedures, and regulatory guidance from CMS, OIG, or other regulatory bodies.