Medicare Risk Adjustment Compliance Analyst

CVS Health; Woonsocket (RI); On-site; USD 47,000 - 112,000; Full time

Benefits offered by this job

Medical, dental, vision coverage

Paid time off

Retirement savings options

Job summary

CVS Health is seeking a Senior Analyst, Compliance COE to play a key role in the Compliance Monitoring team. You will apply healthcare compliance, billing, coding, and risk adjustment knowledge to execute monitoring activities across multiple business areas.

You will coordinate testing, report results, follow up on issues, and communicate compliance risks and business impact to stakeholders. Travel up to 5% may be required.

Qualifications

• 2+ years of experience in healthcare compliance, auditing, monitoring, billing, coding, claims review, medical record review, risk adjustment, investigations, or risk assessments.
• Strong knowledge of CMS Medicare Part B and Part C requirements, Medicare Advantage risk adjustment programs, HCC coding, RAF methodologies, provider documentation standards, medical record validation, coding compliance requirements, and documentation support standards for billed services and submitted diagnosis codes.
• Experience reviewing medical records, claims data, diagnosis codes, modifiers, and supporting documentation to determine whether HCC submissions, RAF impact, billed services, and coding outcomes are accurate, complete, and supported.
• Strong analytical, deductive, problem solving, and critical thinking skills.
• Willingness to travel up to 5% (including by plane)

Responsibilities

• Execute assigned compliance monitoring activities across multiple business areas.
• Coordinate monitoring testing, reporting, issue follow-up, and communication of compliance risks and business impacts.
• Support results communication to stakeholders and cross-functional teams.
• Collaborate with Compliance, Legal, clinical operations, billing and coding teams to resolve risk findings.

Skills

Healthcare compliance

Auditing

Monitoring

Billing

Coding

Risk adjustment

CMS requirements

HCC coding

RAF methodologies

Medical record review

Documentation standards

Education

Bachelor's degree

High School Diploma/GED

CPC certification

Job description

CVS Health is seeking a Senior Analyst, Compliance COE to play a key role in the Compliance Monitoring team. You will apply healthcare compliance, billing, coding, and risk adjustment knowledge to execute monitoring activities across multiple business areas.

You will coordinate testing, report results, follow up on issues, and communicate compliance risks and business impact to stakeholders. Travel up to 5% may be required.