Cigna Healthcare · 5 hours ago

Healthcare Quality Review and Risk Analyst

United States

Contract

Remote

Entry Level

$23/hr - $25/hr

2+ years exp

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Hiring Manager

Alka Mathur

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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, HHS Protocols 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.

Qualification

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ICD-10-CM codingRisk Adjustment ModelMedical documentation auditsCoding certificationsCMS regulationsHCC codingExcelMS WordAdobe AcrobatMedical claims submissions

Required

High school diploma

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

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 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