Legal Compliance Advisor- Medicare Part C Risk Adjustment Monitoring and Audit

at  The Cigna Group

Responsible for Part C audit activities for the Cigna Compliance Department, with particular emphasis on Coding, Risk Adjustment and Coding Decisions. Collaborates with Cigna Compliance colleagues and business partners to drive process improvements, monitor and audit ICD-10 codes submitted to Cigna by providers, identify codes that may be submitted inappropriately and where identified ensure effective corrective action. S/he forges and maintains positive working relationships with business owners, management, regulators and compliance colleagues and demonstrates the ability to influence business partner and/or staff behavior at whatever level and to whatever extent is needed.

To be successful, this candidate must exhibit superior analytical, coding skills (including ICD-9 and ICD-10), strong knowledge of HCC’s and risk scores, communication and collaborative skills, as well as the ability to excel in a dynamic, fast-paced environment. The candidate must demonstrate solid command of risk adjustment. This compliance team member must be adept at working with a variety of internal and external stakeholders. S/he will promote an enterprise-wide culture of compliance and provide first-rate support within the Compliance Department and across the business units.

• Reports to the Part C Legal Compliance Manager;
• Monitors transactions and business processes associated with reconciling ICD-9/ICD-10 codes received from providers with the provider’s medical records as well as establishing the appropriate use of codes received;
• Provides subject matter expertise in response to day-to-day business issues related to coding and risk adjustment;
• Manage a specific caseload of risk adjustment projects as assigned, from start to finish, in a timely manner;
• Monitor transactions related to the risk adjustment process and coding (ICD-9/ICD-10) either onsite, via webinar or by means of a desk review. Monitoring risk adjustment transactions include, amongst others, validating universes, preparing and/or executing programs to monitor and monitoring targeted transactions by way of walk-throughs, conducting interviews, and performing tests/reviews;
• Stay abreast of industry changes and/or trends including but not limited to Federal Risk Adjustment cases;
• Researches guidelines to ensure Cigna coding best practices remain consistent with CMS RADV Coding Guidance and ICD-10 coding guidelines;
• Collaborates with all areas of compliance, the special investigations unit, and business owners to drive process improvements and ensure that corrective action plans are tailored and appropriate for the deficiencies identified; and
• Provide meaningful and appropriate reporting to support compliance audit.

QUALIFICATIONS:

Bachelor’s degree or equivalent.

5+ YEARS OF EXPERIENCE WITH MEDICARE RISK ADJUSTMENT-IS REQUIRED.

5+ years of experience working with Medicare Advantage, Medicare-Medicaid. Plan (Dual-Eligible) and/or Medicaid.

Please refer the Job description for details