Individual & Family Plans (IFP) Quality Review and Audit Analyst - Cigna He at The Cigna Group

, , United States -

Full Time

Start Date

Immediate

Expiry Date

19 Jun, 26

Salary

38.0

Posted On

21 Mar, 26

Experience

2 year(s) or above

Remote Job

Yes

Telecommute

Yes

Sponsor Visa

Skills

Medical Coding, HCC Expertise, Diagnosis Code Abstraction, ICD-10-CM Coding, HHS Risk Adjustment Model, Hierarchical Condition Categories, Data Audits, Compliance Risk Identification, RADV Audit, Vendor Coding Audits, Risk Adjustment Education, Stakeholder Coordination, Program Risk Management, Communication, Process Development, Guideline Updates

Industry

Hospitals and Health Care

Description

The job profile for this position is Quality Review and Audit Analyst, which is a Band 2 Senior Contributor Career Track Role. Excited to grow your career? We value our talented employees, and whenever possible strive to help one of our associates grow professionally before recruiting new talent to our open positions. If you think the open position you see is right for you, we encourage you to apply! Our people make all the difference in our success. Job 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. Education & Experience requirements: 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) 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 Individuals who have a certification other than the CRC must become CRC certified within 6 months of hire. Minimum Qualifications: • 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 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. At The Cigna Group, 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), 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, click here. 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. Please note that you must meet our posting guidelines to be eligible for consideration. Policy can be reviewed at this link. Qualified applicants with criminal histories will be considered for employment in a manner consistent with all federal, state and local ordinances.

Responsibilities

The analyst will conduct medical records reviews, abstract diagnosis codes according to official guidelines, and utilize the HHS Risk Adjustment Model to confirm the accuracy of Hierarchical Condition Categories (HCCs). Key functions also involve performing documentation and data audits to identify gaps and compliance risks for Risk Adjustment programs, including vendor coding quality audits.