Senior Quality Analyst

CVS Health

23h

About The Position

We’re building a world of health around every individual — shaping a more connected, convenient and compassionate health experience. At CVS Health®, you’ll be surrounded by passionate colleagues who care deeply, innovate with purpose, hold ourselves accountable and prioritize safety and quality in everything we do. Join us and be part of something bigger – helping to simplify health care one person, one family and one community at a time. Role Overview Responsible for conducting complex audits, reviews and assessments of medical records coded by internal teams prior to the submission to the Centers of 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. Contributes to compliance reporting and documentation, highlighting findings, recommendations, and areas of concern to be delivered to coding resources. Job Description Demonstrated ability to apply coding judgment and make decisions using industry-standard evidence and tools, exercising independent judgment to determine final outcomes prior to submission with minimal supervision. Adhere to stringent timelines consistent with project deadlines and directives. Demonstrates a strong commitment to enhancing and promoting quality; consistently delivers accurate and thorough work, and supports others in achieving the same standards through effective mentoring and instruction. Serves as the training resource and subject matter expert to vendors, providers and other team members for questions regarding ICD coding and documentation requirements. Comprehensive knowledge of coding guidelines and regulations to meet compliance requirements, such as establishing medical necessity. 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. Evidenced knowledge of problem solving and decision making skills Ability to confidently speak to such evidence across internal or external 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. Acts as mentor to provide education to internal staff based on audit findings; provides general education on ICD codes as appropriate. Communicates with corporate legal and compliance teams to ensure accurate and timely reporting to external authorities. As the need arises, may liase with regulatory bodies, auditors, and legal professionals to address compliance-related matters.

Requirements

• 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.
• Completion of AAPC/AHIMA training program for core credential (CPC, CCS-P) with associated work history/on the job experience equal to approximately 5 years for CPC.
• CPC (Certified Professional Coder) or CCS-P (Certified Coding Specialist-Physician) and CRC (Certified Risk Adjustment Coder) required.

Nice To Haves

• Experience with International Classification of Disease (ICD) codes required.
• Experience with Medicare and/or Commercial and/or Medicaid Risk Adjustment process and Hierarchical Condition Categories (HCC) required.
• Expertise in medical documentation, fraud, abuse and penalties for documentation and coding violations based on governmental guidelines.
• CPMA (Certified Professional Medical Auditor) or CDEO (Certified Documentation Expert Outpatient) preferred.

Responsibilities

• Conducting complex audits, reviews and assessments of medical records coded by internal teams prior to the submission to the Centers of Medicare and Medicaid Services (CMS)
• Contributes to compliance reporting and documentation, highlighting findings, recommendations, and areas of concern to be delivered to coding resources.
• Apply coding judgment and make decisions using industry-standard evidence and tools, exercising independent judgment to determine final outcomes prior to submission with minimal supervision.
• Adhere to stringent timelines consistent with project deadlines and directives.
• Enhancing and promoting quality; consistently delivers accurate and thorough work, and supports others in achieving the same standards through effective mentoring and instruction.
• Serves as the training resource and subject matter expert to vendors, providers and other team members for questions regarding ICD coding and documentation requirements.
• Comprehensive knowledge of coding guidelines and regulations to meet compliance requirements, such as establishing medical necessity.
• 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.
• Ability to confidently speak to such evidence across internal or external 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.
• Acts as mentor to provide education to internal staff based on audit findings; provides general education on ICD codes as appropriate.
• Communicates with corporate legal and compliance teams to ensure accurate and timely reporting to external authorities.
• Liaise with regulatory bodies, auditors, and legal professionals to address compliance-related matters.

Benefits

• Affordable medical plan options, a 401(k) plan (including matching company contributions), and an employee stock purchase plan.
• No-cost programs for all colleagues including wellness screenings, tobacco cessation and weight management programs, confidential counseling and financial coaching.
• Benefit solutions that address the different needs and preferences of our colleagues including paid time off, flexible work schedules, family leave, dependent care resources, colleague assistance programs, tuition assistance, retiree medical access and many other benefits depending on eligibility.

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level