Legal Compliance Advisor- Medicare Part C Risk Adjustment Monitoring and Audit

Cigna - Bluffton, SC

Full-time - Senior

Hybrid - Bluffton, SC

Insurance Carriers and Related Activities

About the position

The Legal Compliance Advisor for Medicare Part C Risk Adjustment Monitoring and Audit at The Cigna Group is responsible for overseeing audit activities related to coding and risk adjustment within the Compliance Department. This role emphasizes collaboration with various stakeholders to ensure compliance with Medicare regulations, particularly focusing on the accuracy of ICD-10 codes submitted by providers. The advisor will drive process improvements, monitor transactions, and provide subject matter expertise to support compliance efforts across the organization.

Responsibilities

• Conduct Part C audit activities focusing on Coding, Risk Adjustment, and Coding Decisions.
• Collaborate with compliance colleagues and business partners to drive process improvements.
• Monitor and audit ICD-10 codes submitted by providers to identify inappropriate submissions and ensure corrective actions are taken.
• Maintain positive working relationships with business owners, management, regulators, and compliance colleagues.
• Exhibit superior analytical and coding skills, particularly in ICD-9 and ICD-10.
• Demonstrate strong knowledge of Hierarchical Condition Categories (HCCs) and risk scores.
• Promote a culture of compliance within the organization and provide support across business units.
• Manage a specific caseload of risk adjustment projects from start to finish in a timely manner.
• Monitor transactions related to the risk adjustment process and coding through various methods including onsite reviews and webinars.
• Stay updated on industry changes and trends related to Federal Risk Adjustment cases.
• Research guidelines to ensure Cigna coding practices align with CMS RADV Coding Guidance and ICD-10 coding guidelines.
• Provide meaningful reporting to support compliance audits.

Requirements

• Bachelor's degree or equivalent.
• 5+ years of experience with Medicare Risk Adjustment.
• 5+ years of experience working with Medicare Advantage, Medicare-Medicaid Plans, and/or Medicaid.
• Certified Coding Specialist certification required.
• 5+ years of experience with auditing.
• Experience with Risk Adjustment Data Validation Audits required.
• Strong knowledge of Medicare Risk Adjustment regulations.
• Strong knowledge of Risk Adjustment and Hierarchical Condition Category Payment model.

Benefits

• Smoking cessation program