Analyst, Coding Data Quality Audit
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Job Description
Coding audit analyst reviewing medical records and ICD codes for CVS Health’s healthcare services. Ensuring CMS risk-adjustment compliance, documentation accuracy, and coding quality.
Responsibilities:
- Perform second-level quality inter-rater review audits of medical records coded by internal teams and external vendors, if applicable
- Ensure ICD codes submitted to CMS for risk adjustment are appropriate, accurate, and supported by clinical documentation
- Support coding judgments and decisions using industry-standard evidence and tools
- Communicate supporting evidence to internal stakeholders with varying levels of coding and clinical expertise
- Mentor and educate internal staff based on audit findings
- Provide general education on ICD coding as appropriate
- Conduct process audits for compliance with internal policies, procedures, CMS regulations, OIG guidance, and other regulatory requirements
- Work independently and collaboratively across cross-functional teams to promote best practices
- Identify and communicate documentation deficiencies to support peer education and development
- Maintain knowledge of coding guidelines, medical necessity, documentation requirements, and fraud and abuse regulations
Requirements:
- Minimum of 3 years of recent, related experience in medical record documentation review, diagnosis coding, and/or auditing
- Associate degree (AA/AS) or equivalent experience
- Completion of an AAPC or AHIMA training program for a core credential (CPC or CCS-P), with associated work history and on-the-job experience equivalent to approximately 3 years for CPC certification
- CPC (Certified Professional Coder) or CCS-P (Certified Coding Specialist-Physician) certification required
- CRC (Certified Risk Adjustment Coder) certification required within the first six months
- Knowledge of coding guidelines and regulations
- Knowledge of medical documentation requirements, fraud and abuse regulations, and penalties associated with documentation and coding violations
- Ability to support coding judgments using industry-standard evidence and tools
- Ability to communicate evidence to internal stakeholders, clinical staff, coding staff, federal regulators, and vendor coding resources
- Ability to work independently and collaboratively across cross-functional teams
- Ability to meet stringent timelines and project deadlines
Benefits:
- CVS Health bonus, commission or short-term incentive program in addition to the base pay range
- Medical coverage
- Dental coverage
- Vision coverage
- Paid time off
- Retirement savings options
- Wellness programs
- Other resources supporting physical, emotional, and financial well-being, based on eligibility
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