Quality Review and Audit Analyst - Cigna Healthcare - Remote

Job Summary: The Quality Review & Audit Senior Analyst (“Analyst”) exhibits expertise in evaluating complex medical documentation for diagnosis code accuracy and compliance in support of the HHS’ Risk Adjustment (RA) program and Risk Adjustment Data Validation (RADV) audits. The Senior Analyst is responsible for all aspects of auditing medical documentation for diagnostic code abstraction, and possesses HHS’ Hierarchical Condition Category (HCC) expertise, evaluating data accuracy and record compliance, executing on audit requirements, and identifying and recommending process improvements within the RA program. Core Responsibilities:

• Proficient in assigning accurate ICD-10 diagnosis codes in accordance with Official Coding Guidelines and Conventions, Cigna IFP Coding Guidelines, and HHS’ RADV Protocols Audits accuracy of abstracted diagnostic codes from identified medical record cohorts, evaluating work of peers and/or coding vendor coders, to ensure compliance with quality standards, scoring as appropriate per monthly quality feedback reports or other scoring instrument, as defined per policy.
• Performs claims matching and auditing, as required, identifying missing or inaccurate data within RA claims and ensuring compliance with HHS’ RA program protocols.
• Leads, trains, or mentors junior team members, as required, sharing expertise in RA programs.
• Contributes to execution of Risk Adjustment programs, and other IFP programs, as needed, to ensure accurate and compliant data submissions.
• Collaborates and coordinates with stakeholders to facilitate coding and risk adjustment education.
• Contributes expertise to creation and maintenance of Coding Guidelines and Best Practices, as needed.
• Participates in RADV execution for designated markets, including but not limited to, medical records reviews; subordinate, peer, or vendor coding audits; evaluation and reporting of progress, barriers, or errors; or other tasks as defined in HHS’ RADV Protocols. Minimum Qualifications:
• High School Diploma or equivalent; Bachelors or equivalent work experience preferred
• 5+ years’ experience in medical record coding, with certification in good standing from either the American Academy of Professional Coders (AAPC) or the American Health Information Management Association (AHIMA), in one or more of the following: ▪ 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)
• Willing to achieve CRC certification within 12 months of hire, if not previously certified
• Experience with Risk Adjustment coding and HCCs, demonstrating proficiency in ICD-10-CM medical diagnosis coding
• Familiarity with CMS regulations for Risk Adjustment programs helpful.
• Medical claims, billing, or inpatient coding experience helpful
• Competency with MS Excel, MS Word, Adobe Acrobat, or other comparable software
• Must be detail oriented, self-motivated, and have excellent organization skills, with the ability to communicate professionally and effectively in all formats (verbal, written, electronic)
• Ability to work independently, managing time to meet deadlines, timelines, productivity, and accuracy standards for program success 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 annual salary of 58,400 - 97,400 USD / yearly, 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. About Cigna Healthcare Cigna Healthcare, a division of The Cigna Group, is an advocate for better health through every stage of life. We guide our customers through the health care system, empowering them with the information and insight they need to make the best choices for improving their health and vitality. Join us in driving growth and improving lives. 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. If you need a reasonable accommodation to complete the online application process, please email [email protected] for assistance. Please note that this email inbox is dedicated to accommodation requests only and cannot provide application updates or accept resumes. The Cigna Group has a tobacco-free policy and reserves the right not to hire tobacco/nicotine users in states where that is legally permissible. Candidates in such states who use tobacco/nicotine will not be considered for employment unless they enter a qualifying smoking cessation program prior to the start of their employment. These states include: Alabama, Alaska, Arizona, Arkansas, Delaware, Florida, Georgia, Hawaii, Idaho, Iowa, Kansas, Maryland, Massachusetts, Michigan, Nebraska, Ohio, Pennsylvania, Texas, Utah, Vermont, and Washington State. Qualified applicants with criminal histories will be considered for employment in a manner consistent with all federal, state and local ordinances. Doing something meaningful starts with a simple decision, a commitment to changing lives. At The Cigna Group, we’re dedicated to improving the health and vitality of those we serve. Through our divisions Cigna Healthcare and Evernorth Health Services, we are committed to enhancing the lives of our clients, customers and patients. Join us in driving growth and improving lives.

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