Individual & Family Plans (IFP) Quality Review and Audit Analyst - Remote - Cigna Healthcare

Cigna; Bloomfield (IA); Remote; USD 60,000 - 80,000; Full time

Job summary

An established industry player is seeking a Quality Review and Audit Analyst to conduct medical record reviews and ensure compliance with coding guidelines. This role is pivotal in supporting Risk Adjustment programs and involves collaborating with various teams to enhance coding education. The ideal candidate will possess a strong background in ICD-10-CM coding, critical thinking skills, and a commitment to continuous quality improvement. Join this dynamic team and contribute to impactful healthcare solutions while enjoying a comprehensive benefits package and a supportive work environment focused on your health and well-being.

Benefits

Medical Insurance

Vision Insurance

Dental Insurance

401(k) with Company Match

Tuition Reimbursement

Paid Time Off

Paid Holidays

Life Insurance

Qualifications

• At least 2 years of Risk Adjustment experience.
• Proficiency with ICD-10-CM coding guidelines.
• Knowledge of CMS regulations related to documentation.

Responsibilities

• Conduct medical record reviews and assign ICD-10-CM codes accurately.
• Perform documentation audits and identify compliance risks.
• Collaborate with team members for coding education.

Skills

ICD-10-CM Coding

Risk Adjustment Knowledge

Medical Record Review

Critical Thinking

Compliance Knowledge

Communication Skills

Attention to Detail

Education

High School Diploma

Certified Professional Coder (CPC)

Certified Risk Adjustment Coder (CRC)

Tools

Microsoft Outlook

Microsoft Excel

Microsoft Word

Adobe Acrobat

Job description

Primary Functions:

Responsible for conducting medical record reviews, accurately assigning ICD-10-CM diagnostic codes based on medical record documentation and auditing medical charts for Hierarchical Condition Categories (HCC), as defined by HHS' Risk Adjustment model. Responsible for performing various documentation and data audits with identification of gaps 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. Responsible for collaborating and coordinating, as required, with team members to facilitate coding education with internal and external partners, as well as performing quality reviews of vendor partner coding output.

Contributes to Cigna IFP Coding Guideline updates and policy determinations, as needed. The Quality Review and Audit Analyst position recognizes individuals experienced in Risk Adjustment processes, medical record and diagnosis coding excellence, Continuous Quality Improvement (CQI) processes, and the ability to communicate programs and processes to peers, colleagues, and Matrix Partners.

Essential Duties:

• Review of medical records with accurate diagnosis code abstraction in accordance with Official Coding Guidelines and Conventions, Cigna IFP Coding Guidelines and Best Practices, and any application rule set.
• Comprehensive understanding and proficiency with the Complete Official Code Set, Coding Clinic, and CMS guidelines for code abstraction and medical record compliance
• Knowledge and application of Risk Adjustment models when reviewing medical records for code abstraction, with emphasis on HCC identification and CMS compliance for Risk Adjustment programs.
• Demonstration of critical thinking and application of Program regulations and guidelines for Risk Adjustment Data Validation (RADV) audits and Supplemental Diagnosis programs.
• Comprehensive understanding of RADV Protocols and Compliance Requirements for RA programs, including EDGE Server Business Rules, where applicable.
• Coordinates with external partners to execute efficient and compliant programs
• Identifies risks or program gaps and communicate effectively to management in a timely manner
• Demonstrates ability to complete assigned tasks by prescribed deadlines, and meet required productivity standards
• Develops and implements internal program processes, as required
• Remains current on Federal regulations related to diagnosis coding and the HHS Risk Adjustment program, including audit protocols
• Practices effective communication skills with peers and matrix partners to ensure Continuous Quality Improvement and ensure compliance with all CMS guidelines and regulations;
• Proficiency with Microsoft Outlook, Microsoft Excel, Microsoft Word
• Practices clear, concise, and professional communication with peers and supervisors, in verbal, telephonic, and written communication
• Demonstrates knowledge of HIPAA guidelines and protection of PHI in physical and electronic environments, or other means, as applicable.
• Demonstrates the ability to follow verbal and written directions accurately and timely
• Demonstrates the ability to follow all applicable policies and procedures
• Ability to work independently to accomplish assigned work within the allocated time, meeting deadlines as prescribed
• Demonstrates ability and willingness to assume other duties as requested, which may or have not be listed in the job description

Minimum Qualifications

• High School Diploma
• At least two(2) year's Risk Adjustment experience, with certification by either the American Health Information Management Association (AHIMA) or the American Academy of Professional Coders (AAPC) in one of the following certifications:
  • 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
• Achieve CRC certification within 6 months of hire, if not currently certified
• Risk Adjustment experience/CMS knowledge required
• Experience with medical audits and medical chart reviews
• Proficiency with ICD-10-CM coding guidelines and conventions
• Familiarity with CMS regulations and polices related to documentation and coding, both with Inpatient and Outpatient documentation
• HCC coding experience preferred
• Computer competency with excel, MS Word, Adobe Acrobat
• Must be detail oriented, self-motivated, and have excellent organization skills
• Understanding of medical claims submissions, helpful

If you will be working at home occasionally or permanently, the internet connection must be obtained through a cable broadband or fiber optic internet service provider with speeds of at least 10Mbps download/5Mbps upload.

For this position, we anticipate offering an hourly rate of 25 - 38 USD / hourly, depending on relevant factors, including experience and geographic location.

This role is also anticipated to be eligible to participate in an annual bonus plan.

We want you to be healthy, balanced, and feel secure. That's why you'll enjoy a comprehensive range of benefits, with a focus on supporting your whole health. Starting on day one of your employment, you'll be offered several health-related benefits including medical, vision, dental, and well-being and behavioral health programs. We also offer 401(k) with company match, company paid life insurance, tuition reimbursement, a minimum of 18 days of paid time off per year and paid holidays. For more details on our employee benefits programs, visit Life at Cigna Group .

About Cigna Healthcare

Cigna Healthcare, a division of The Cigna Group, is an advocate for better health through every stage of life. We guide our customers through the health care system, empowering them with the information and insight they need to make the best choices for improving their health and vitality. Join us in driving growth and improving lives.

Qualified applicants will be considered without regard to race, color, age, disability, sex, childbirth (including pregnancy) or related medical conditions including but not limited to lactation, sexual orientation, gender identity or expression, veteran or military status, religion, national origin, ancestry, marital or familial status, genetic information, status with regard to public assistance, citizenship status or any other characteristic protected by applicable equal employment opportunity laws.

If you require reasonable accommodation in completing the online application process, please email: [e-mail] for support. Do not email [e-mail] for an update on your application or to provide your resume as you will not receive a response.

The Cigna Group has a tobacco-free policy and reserves the right not to hire tobacco/nicotine users in states where that is legally permissible. Candidates in such states who use tobacco/nicotine will not be considered for employment unless they enter a qualifying smoking cessation program prior to the start of their employment. These states include: Alabama, Alaska, Arizona, Arkansas, Delaware, Florida, Georgia, Hawaii, Idaho, Iowa, Kansas, Maryland, Massachusetts, Michigan, Nebraska, Ohio, Pennsylvania, Texas, Utah, Vermont, and Washington State.

Qualified applicants with criminal histories will be considered for employment in a manner consistent with all federal, state and local ordinances.