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Aetna’s Revenue Integrity team is hiring Senior Coding Data Quality Auditors to support our growing risk adjustment efforts. This role plays a critical part in ensuring coding accuracy and data integrity, directly impacting compliance and financial performance. Ideal candidates will bring a strong understanding of coding standards and auditing practices, along with a passion for continuous improvement. This position will sit within our Coding Quality Operations team and offers the flexibility of working from home.

POSITION SUMMARY

• Responsible for performing second level quality inter-rater review audits of medical records coded by internal team, as well as external vendor (if applicable) to ensure the ICD codes that are submitted to the Centers for Medicare and Medicaid Services (CMS) for the purpose of risk adjustment processes are appropriate, accurate, and supported by clinical documentation in accordance with all State and Federal regulations and internal policies and procedures.
• Proven ability to support coding judgment and decisions using industry standard evidence and tools.
• Ability to confidently speak to such evidence across internal stakeholders with varying knowledge and clinical expertise in either written or verbal forms including communication with clinical or coding staff, federal regulators and vendor coding resources.
• Acts as mentor to provide education to internal staff based on audit findings; provides general education on ICD codes as appropriate
• Conducts process audits to ensure compliance with internal policies and procedures and existing CMS regulations.
• Ability to work independently as well as in a cross functional role within other teams for collaboration on best practices.
• Adhere to stringent timelines consistent with project deadlines and directives.
• Possesses a genuine interest in improving and promoting quality; demonstrates accuracy and thoroughness and assists others to achieve the same through mentoring and instruction.
• Conducts process audits to ensure compliance with internal policies and procedures as well as regulatory guidance from CMS, OIG or other Regulatory body.
• Thorough knowledge of coding guidelines and regulations to meet compliance requirements, such as establishing medical necessity.
• Identify and communicate documentation deficiencies to allow for continuous education opportunities for peers.
• Extensive knowledge of medical documentation, fraud, abuse and penalties for documentation and coding violations based on governmental guidelines.

REQUIRED QUALIFICATIONS

• Minimum of 3 years recent and related experience in medical record documentation review, diagnosis coding, and/or auditing.
• CPC (Certified Professional Coder) or CCS-P (Certified Coding Specialist-Physician) required.
• Experience with International Classification of Disease (ICD) codes required.
• Experience with Medicare and/or Commercial and/or Medicaid Risk Adjustment process and Hierarchical Condition Categories (HCC) required.
• CRC (Certified Risk Adjustment Coder) required within the first six months.

PREFERRED QUALIFICATIONS

• Computer proficiency including experience with Microsoft Office products (Word, Excel, Access, PowerPoint, Outlook, industry standard coding applications).
• Expertise in medical documentation, fraud, abuse and penalties for documentation and coding violations based on governmental guidelines.

EDUCATION

• AA/AS or equivalent experience
• Completion of AAPC/AHIMA training program for core credential (CPC, CCS-P) with associated work history/on the job experience equal to approximately 3 years for CPC.

Please refer the Job description for details