Quality Review and Audit Senior Representative

Pyramid Consulting, Inc; United States; Remote; Full time

Job summary

A leading company in the insurance industry seeks a Quality Review and Audit Senior Representative for a remote position. The role requires expertise in risk adjustment and auditing, focusing on quality audits and documentation accuracy. Join us to make an impact and ensure compliance in a growing field.

Benefits

Health insurance (medical, dental, vision)

401(k) plan

Paid sick leave

Qualifications

• 2 years of experience in relevant coding certifications is required.
• Proficiency with ICD-10-CM coding guidelines necessary.
• Must be detail-oriented and possess excellent organizational skills.

Responsibilities

• Conduct medical records reviews and audits based on coding guidelines.
• Coordinate with stakeholders for effective and compliant risk adjustment programs.
• Develop and implement processes ensuring compliance with CMS/HHS regulations.

Skills

Risk Adjustment

Auditing

CPC

CRC

Education

High School Diploma

Certified Professional Coder (CPC)

Certified Coding Specialist for Providers (CCS-P)

Registered Health Information Administrator (RHIA)

Tools

Excel

MS Word

Adobe Acrobat

Job description

Quality Review and Audit Senior Representative

Quality Review and Audit Senior Representative

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Pyramid Consulting, Inc provided pay range

This range is provided by Pyramid Consulting, Inc. Your actual pay will be based on your skills and experience — talk with your recruiter to learn more.

Base pay range

$25.00/hr - $26.50/hr

Immediate need for a talented Quality Review and Audit Senior Representative. This is a 03+ months contract opportunity with long-term potential and is located in U.S(Remote). Please review the job description below and contact me ASAP if you are interested.

Job ID: 25-72837

Pay Range: $25 - $26.50/hour. Employee benefits include, but are not limited to, health insurance (medical, dental, vision), 401(k) plan, and paid sick leave (depending on work location).

Key Responsibilities:

• Conduct medical records reviews with accurate diagnosis code abstraction in accordance with Official Coding Guidelines and Conventions, Client 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 Client IFP Coding Guideline updates and policy determinations, as needed.

Key Requirements and Technology Experience:

• Key skills; CRC, CPC, Risk Adjustment, and Auditing
• 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):
• Certified Professional Coder (CPC) o Certified Coding Specialist for Providers (CCS-P)
• Certified Coding Specialist for Hospitals (CCS-H)
• Registered Health Information Administrator (RHIA)
• 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 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 is preferred
• Ability to meet timeline, productivity, and accuracy standards

Our client is a leading Insurance Industry and we are currently interviewing to fill this and other similar contract positions. If you are interested in this position, please apply online for immediate consideration.

Pyramid Consulting, Inc. provides equal employment opportunities to all employees and applicants for employment and prohibits discrimination and harassment of any type without regard to race, color, religion, age, sex, national origin, disability status, genetics, protected veteran status, sexual orientation, gender identity or expression, or any other characteristic protected by federal, state or local laws.

By applying to our jobs, you agree to receive calls, AI-generated calls, text messages, or emails from Pyramid Consulting, Inc. and its affiliates, and contracted partners. Frequency varies for text messages. Message and data rates may apply. Carriers are not liable for delayed or undelivered messages. You can reply STOP to cancel and HELP for help. You can access our privacy policy here.

Seniority level

• Seniority level

  Not Applicable

Employment type

• Employment type

  Contract

Job function

• Job function

  Quality Assurance

• Industries

  Insurance

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