Quality Review and Audit Analyst

The Cigna Group; Franklin (TN); Remote; USD 33,000 - 37,000; Full time

Benefits offered by this job

Medical

Dental

Vision

401K

Job summary

The Cigna Group is seeking a Quality Review and Audit Analyst for a fully remote role supporting Risk Adjustment within the IFP program. The candidate will apply medical coding expertise to review complex conditions, ensure documentation compliance, and identify improvement opportunities in data and processes for CQI.

Responsibilities include conducting records reviews, validating HCC accuracy, performing audits for RADV and supplementary submissions, and collaborating with internal and external

Qualifications

• Two+ years' experience with medical documentation audits and ICD-10-CM coding guidelines and conventions.
• Familiarity with CMS regulations for Risk Adjustment programs and policies related to documentation and coding compliance.
• HCC coding experience.
• Proficiency with Excel, Word, and Acrobat for documentation and audits.

Responsibilities

• Conduct medical records reviews with accurate diagnosis code abstraction in accordance with Official Coding Guidelines and Conventions.
• Utilize HHS Risk Adjustment Model to confirm accuracy of HCC identified from ICD-10-CM codes.
• Apply longitudinal thinking to identify data elements and opportunities for data capture within HHS Risk Adjustment.
• Perform data audits identifying gaps and compliance risks in RA programs and RADV workflows.
• Collaborate with team members and partners to support coding and Risk Adjustment education.
• Coordinate with stakeholders to execute compliant RA programs and raise risks to management.

Skills

Risk Adjustment

HHS Risk Adjustment

Education

CPC

CCS-P

CCS-H

RHIT

RHIA

CRC certification

Tools

Excel

MS Word

Adobe Acrobat

Job description

Skills

• Risk Adjustment

This position is a temporary assignment. As a contractor, you’ll be employed by Magnit, not The Cigna Group or any subsidiaries of The Cigna Group.

Job Title: Quality Review and Audit Analyst

LOCATION AND SCHEDULE

Monday - Friday no earlier than 6:30am EST and no later than 9am EST - work 8 hours shift with 30 minute lunch

Training Schedule 9am - 5:30pm EST 100% Remote

This is a fully remote role open to candidates across the US.

Role Summary

The Risk Adjustment Quality & Review Analyst in IFP brings medical coding and Hierarchical Condition Category expertise to the role, evaluates complex medical conditions, determines compliance of medical documentation, identifies trends, and suggests improvements in data and processes for Continuous Quality Improvement (CQI).

Key Job Functions

• 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.

Skills

• Risk Adjustment
• HHS Risk Adjustment

Requirements

• 2+ years' Experience with medical documentation audits and medical chart reviews and 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.
• HCC coding experience
• Computer competency with excel, MS Word, Adobe Acrobat
• Must be detail oriented, self-motivated, and have excellent organization skills
• Understanding of medical claims submissions is preferred
• Ability to meet timeline, productivity, and accuracy standards

Education

The Quality Review & Audit Analyst will have a high school diploma and 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):

Active Certifications (at Least One)

• 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

Hourly Pay Rate Range (dependent on location, experience, expectation)

The pay range that Magnit reasonably expects to pay for this position is: $24.00/hour-$27.00/hour

Benefits

• Medical
• Dental
• Vision
• 401K(provided minimum eligibility hours are met)

The operation of this talent community is a global leader of contingent talent services. Our success and our clients’ success are built on a foundation of service excellence. We are an equal opportunity employer, and we do not discriminate on the basis of race, religion, color, national origin, sex, sexual orientation, age, veteran status, disability, genetic information, or other applicable legally protected characteristic. Qualified applicants with arrest or conviction records will be considered for employment in accordance with applicable law, including the Los Angeles County Fair Chance Ordinance for Employers and the California Fair Chance Act. Unincorporated LA County workers: we reasonably believe that criminal history may have a direct, adverse and negative relationship with the following job duties, potentially resulting in the withdrawal of a conditional offer of employment: client provided property, including hardware (both of which may include data) entrusted to you from theft, loss or damage; return all portable client computer hardware in your possession (including the data contained therein) upon completion of the assignment, and; maintain the confidentiality of client proprietary, confidential, or non-public information. In addition, job duties require access to secure and protected client information technology systems and related data security obligations.

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.