Quality Review and Audit Analyst
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Job Description
Risk Adjustment Quality Analyst reviewing medical records, HCC coding, and CMS compliance for Cigna Healthcare. Auditing data and supporting compliant health-plan risk-adjustment programs.
Responsibilities:
- Conduct medical record reviews and accurately abstract diagnosis codes according to official, Cigna, HHS, and applicable coding guidelines.
- Use the HHS Risk Adjustment Model to validate Hierarchical Condition Categories identified from ICD-10-CM codes for the correct Benefit Year.
- Apply longitudinal review to identify valid data elements and opportunities for risk-adjustment data capture.
- Perform documentation and data audits, identify risk-adjustment data gaps, inaccuracies, and compliance risks, and support RADV audits and Supplement Diagnosis submissions.
- Conduct quality audits of vendor coding partners.
- Collaborate with team members and matrix partners on coding and Risk Adjustment education for internal and external partners.
- Coordinate with stakeholders to execute efficient and compliant Risk Adjustment programs and escalate risks or gaps to management.
- Develop and implement internal processes for CMS/HHS-compliant programs.
- Contribute to Cigna IFP Coding Guideline updates and policy determinations.
Requirements:
- High school diploma
- 2+ years’ experience in one of the listed coding certifications or Certified Risk Adjustment Coder (CRC) certification
- Coding certification from AHIMA or AAPC, including CPC, CCS-P, CCS-H, RHIT, RHIA, or CRC
- Individuals with a certification other than CRC must become CRC certified within 6 months of hire
- Experience with medical documentation audits and medical chart reviews
- Proficiency with ICD-10-CM coding guidelines and conventions
- Familiarity with CMS regulations for Risk Adjustment programs and documentation and coding compliance policies for inpatient and outpatient documentation
- HCC coding experience preferred
- Computer competency with Excel, MS Word, and Adobe Acrobat
- Understanding of medical claims submissions preferred
- Ability to meet timeline, productivity, and accuracy standards
- Must be detail oriented, self-motivated, and have excellent organization skills
- For home working, cable broadband or fiber optic internet service with at least 10Mbps download and 5Mbps upload
Benefits:
- Annual bonus plan eligibility
- Medical, vision, and dental benefits starting on day one
- Well-being and behavioral health programs
- 401(k)
- Company-paid life insurance
- Tuition reimbursement
- Minimum of 18 days of paid time off per year
- Paid holidays
- Leaves of absence
- Tobacco-free policy and smoking cessation program eligibility where applicable
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