Apply on Employer Site

The Cigna Group · 1 day ago

Quality Review and Audit Analyst (36750958)

United States

Contract

Remote

Entry Level

$24/hr - $27/hr

2+ years exp

The Cigna Group is seeking a Risk Adjustment Quality & Review Analyst to evaluate complex medical conditions and ensure compliance of medical documentation. This role involves conducting medical records reviews, performing audits, and collaborating with team members to improve data quality and processes.

CommercialHealth CareHospitalInsuranceMedical

No H1B

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

ICD-10-CM codingRisk Adjustment expertiseMedical documentation auditsCoding CertificationsCMS regulations knowledgeData auditsComputer competencyDetail orientedSelf-motivatedOrganizational skillsCommunication skills

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)

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 organizational skills

Ability to meet timeline, productivity, and accuracy standards