Quality Review and Audit Analyst

Position Title: Quality Review and Audit Analyst
Assignment Duration: 3+ months
Work Schedule: Monday - Friday, 8-hour shift, Training Hours 9am - 5:30pm EST
Work Arrangement: Remote

Position 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 Responsibilities:
• 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 stakeholders 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 IFP Coding Guideline updates and policy determinations, as needed.

Qualification & Experience:
• High school diploma required; Coding Certification by AHIMA or AAPC required. Certifications include CPC, CCS-P, CCS-H, RHIT, RHIA, or CRC.
• 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.

Additional Information (If Applicable):
3 Non-Negotiable Skills:
HCC Knowledge or Experience (Basic)
Active Certification (at least 1)
Basic knowledge of Microsoft products especially Excel.

 

At SPECTRAFORCE, we are committed to maintaining a workplace that ensures fair compensation and wage transparency in adherence with all applicable state and local laws. This position's starting pay is: $29.30/hr.