CVS Health · 1 month ago
Coding Data Quality Auditor
United States
Full-time
Remote
Mid, Senior Level
$18.50/hr - $38.82/hr
2+ years expCVS Health is dedicated to building a world of health around every individual, providing a connected and compassionate health experience. The Coding Data Quality Auditor is responsible for performing quality audits of medical records to ensure accurate coding in compliance with regulations, while also mentoring staff and leading dispute resolution.
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Responsibilities
Responsible for performing quality inter-rater review audits of medical records coded by internal team (CDQA and Sr CDQA) to ensure the ICD-10 codes that are submitted to the Centers for 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
Proven ability to support coding judgment and decisions using industry standard evidence and tools
Ability to confidently speak to such evidence across 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
Leads dispute resolution
Acts as mentor to provide education to internal staff based on audit findings; provides general education on ICD codes as appropriate
Effectively communicates the audit process and results to appropriate departments and management
Conducts process audits to ensure compliance with internal policies and procedures and existing CMS regulations
Identifies and recommends opportunities for process improvements so that productivity and quality goals can be met or exceeded and operational efficiency and final accuracy is achieved
Ability to work independently as well as in a cross functional role within other teams for collaboration on best practices
Adhere to stringent timelines consistent with project deadlines and directives
Must possess high level of dependability and is able to meet coding accuracy and production standards
Monitors own work to help ensure quality
Required to act in ethical manner at all times as required under HIPAA's Privacy and Security rules to handle patient data with uncompromised adherence to the law
Possesses a genuine interest in improving and promoting quality; demonstrates accuracy and thoroughness and assists others to achieve the same through mentoring and instruction
Medical record auditing skills and abstraction expertise
Serves as the training resource and subject matter expert to vendors, providers and other team members for questions regarding ICD coding and documentation requirements
Conducts process audits to ensure compliance with internal policies and procedures as well as regulatory guidance from CMS, OIG or other Regulatory body
Expertise in assigning accurate medical codes for diagnoses as documented for physicians and other qualified healthcare providers in the office and/or facility setting
Thorough knowledge of coding guidelines and regulations to meet compliance requirements, such as establishing medical necessity
In depth knowledge of medical terminology and anatomy for all body systems.-Understand the audit process for risk adjustment models
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
Apply AHA Coding Clinic guidance to identify and resolve coding issues.-Remains current on educational training and requirements including ICD coding, CMS documentation requirements, and State and Federal regulations
Performs other related duties as required
Qualification
Required
CPC (Certified Professional Coder) or CCS-P (Certified Coding Specialist-Physician)
CRC (Certified Risk Adjustment Coder) must be able to obtain within 1 year of employment)
Computer proficiency including experience with Microsoft Office products (Word, Excel, Access, PowerPoint, Outlook, industry standard coding applications)
Experience with International Classification of Disease (ICD) codes required
Minimum of 2 years recent and related experience in medical record documentation review, diagnosis coding, and/or auditing
Preferred
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 CRC (HCC)CPMA (Certified Professional Medical Auditor), CDEO (Certified Documentation Expert Outpatient) or CPC-I (Certified Professional Coding Instructor) preferred
Excellent analytical and problem solving skills. Superior communication, organizational, and interpersonal skills
Benefits
Affordable medical plan options
401(k) plan (including matching company contributions)
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
Company
CVS Health
CVS Health is a health solutions company that provides an integrated healthcare services to its members.
10001+ employees
H1B Sponsorship
CVS Health has a track record of offering H1B sponsorships. Please note that this does not
guarantee sponsorship for this specific role. Below presents additional info for your
reference. (Data Powered by US Department of Labor)
Distribution of Different Job Fields Receiving Sponsorship
Represents job field similar to this job
Trends of Total Sponsorships
2022 (1)
Funding
Current Stage
Public CompanyTotal Funding
$4BKey Investors
Michigan Economic Development CorporationStarboard Value
2025-08-15Post Ipo Debt· $4B
2025-07-17Grant· $1.5M
2019-11-25Post Ipo Equity
Leadership Team
David Joyner
President and Chief Executive Officer, CVS Health
Chandra McMahon
SVP & CISO
Recent News
2026-01-25
Company data provided by crunchbase