Note: The job is a remote job and is open to candidates in USA. CVS Health is a healthcare company focused on creating a more connected, convenient, and compassionate health experience. The Analyst, Coding Data Quality Auditor performs inter-rater reviews and medical record audits to ensure ICD-10 coding is accurate, supported by clinical documentation, and compliant with CMS, state, and federal requirements. The role also provides coding education, resolves disputes, supports process improvements, and serves as a subject matter expert for risk adjustment coding.
Responsibilities
- Proven ability to support coding judgment and decisions using industry standard evidence and tools
- Ability to confidently speak to such evidence across 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
- Leads dispute resolution
- Acts as mentor to provide education to internal staff based on audit findings; provides general education on ICD codes as appropriate
- Effectively communicates the audit process and results to appropriate departments and management
- Conducts process audits to ensure compliance with internal policies and procedures and existing CMS regulations
- Identifies and recommends opportunities for process improvements so that productivity and quality goals can be met or exceeded and operational efficiency and final accuracy is achieved
- 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
- Must possess high level of dependability and is able to meet coding accuracy and production standards
- Monitors own work to help ensure quality
- Required to act in ethical manner at all times as required under HIPAA's Privacy and Security rules to handle patient data with uncompromised adherence to the law
- Possesses a genuine interest in improving and promoting quality; demonstrates accuracy and thoroughness and assists others to achieve the same through mentoring and instruction
- Medical record auditing skills and abstraction expertise
- Serves as the training resource and subject matter expert to vendors, providers and other team members for questions regarding ICD coding and documentation requirements
- Conducts process audits to ensure compliance with internal policies and procedures as well as regulatory guidance from CMS, OIG or other Regulatory body
- Expertise in assigning accurate medical codes for diagnoses as documented for physicians and other qualified healthcare providers in the office and/or facility setting
- Thorough knowledge of coding guidelines and regulations to meet compliance requirements, such as establishing medical necessity
- In depth knowledge of medical terminology and anatomy for all body systems
- Understand the audit process for risk adjustment models
- Identify and communicate documentation deficiencies to allow for continuous education opportunities for providers, vendors and peers
- Expertise in medical documentation, fraud, abuse and penalties for documentation and coding violations based on governmental guidelines
- Apply AHA Coding Clinic guidance to identify and resolve coding issues
- Remains current on educational training and requirements including ICD coding, CMS documentation requirements, and State and Federal regulations
- Performs other related duties as required
Skills
- * Computer proficiency including experience with Microsoft Office products (Word, Excel, Access, PowerPoint, Outlook, industry standard coding applications)
- * Experience with International Classification of Disease (ICD) codes required
- * Minimum of 5 years recent and related experience in medical record documentation review, diagnosis coding, and/or auditing
- * Experience with Medicare and/or Commercial and/or Medicaid Risk Adjustment process and Hierarchical Condition Categories (HCC) required
- * CPC (Certified Professional Coder) or CCS-P (Certified Coding Specialist-Physician) AND CRC (Certified Risk Adjustment Coder) required
- * BA/BS or equivalent experience
- * CPMA (Certified Professional Medical Auditor), CDEO (Certified Documentation Expert Outpatient) or CPC-I (Certified Professional Coding Instructor) preferred
- * Excellent analytical and problem solving skills
- * Superior communication, organizational, and interpersonal skills
- * ### 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
- * ### 5-8 years encompassing additional credentials and/or application of credentials
Benefits
- Eligible for a CVS Health bonus, commission or short-term incentive program in addition to the base pay range listed above.
- This full-time position is eligible for a comprehensive benefits package designed to support the physical, emotional, and financial well-being of colleagues and their families.
- Medical, dental, and vision coverage, based on eligibility.
- Paid time off, based on eligibility.
- Retirement savings options, based on eligibility.
- Wellness programs, based on eligibility.
- Other resources supporting the physical, emotional, and financial well-being of colleagues and their families, based on eligibility.
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