Quality Review and Audit Analyst

The Cigna Group

1d•$25 - $38•Remote

About The Position

The Risk Adjustment Quality & Review Analyst in IFP brings medical coding and Hierarchical Condition Category expertise to the role, evaluates complex medical conditions, determines compliance of medical documentation, identifies trends, and suggests improvements in data and processes for Continuous Quality Improvement (CQI).

Requirements

High school diploma and at least 2 years’ experience in one of the following Coding Certifications by either the American Health Information Management Association (AHIMA) or the American Academy of Professional Coders (AAPC): Certified Professional Coder (CPC), Certified Coding Specialist for Providers (CCS-P), Certified Coding Specialist for Hospitals (CCS-H), Registered Health Information Technician (RHIT), Registered Health Information Administrator (RHIA), Certified Risk Adjustment Coder (CRC) certification.
Individuals who have a certification other than the CRC must become CRC certified within 6 months of hire.
Experience with medical documentation audits and medical chart reviews and proficiency with ICD-10-CM coding guidelines and conventions
Familiarity with CMS regulations for Risk Adjustment programs and policies related to documentation and coding compliance, with both Inpatient and Outpatient documentation
Computer competency with excel, MS Word, Adobe Acrobat
Must be detail oriented, self-motivated, and have excellent organization skills
Ability to meet timeline, productivity, and accuracy standards

Nice To Haves

HCC coding experience preferred
Understanding of medical claims submissions is preferred

Responsibilities

Conduct medical records reviews with accurate diagnosis code abstraction in accordance with Official Coding Guidelines and Conventions, Cigna IFP Coding Guidelines and Best Practices, and any additional applicable rule set.
Utilize HHS’ Risk Adjustment Model to confirm accuracy of Hierarchical Condition Categories (HCC) identified from abstracted ICD-10-CM diagnosis codes for the correct Benefit Year.
Apply longitudinal thinking to identify all valid and appropriate data elements and opportunities for data capture, through the lens of HHS’ Risk Adjustment.
Perform various documentation and data audits with identification of gaps and/or inaccuracies in risk adjustment data and identification of compliance risks in support of IFP Risk Adjustment (RA) programs, including the Risk Adjustment Data Validation (RADV) audit and the Supplement Diagnosis submission program. Inclusive of Quality Audits for vendor coding partners.
Collaborate and coordinate with team members and matrix partners to facilitate various aspects of coding and Risk Adjustment education with internal and external partners.
Coordinate with stake holders to execute efficient and compliant RA programs, raising any identified risks or program gaps to management in a timely manner.
Communicate effectively across all audiences (verbal & written).
Develop and implement internal program processes ensuring CMS/HHS compliant programs, including contributing to Cigna IFP Coding Guideline updates and policy determinations, as needed.