Quality Review and Audit Analyst

🔥 14 hours ago

🎸 Tennessee – Remote

🎸 Tennessee – Remote

⏰ Full Time

🟢 Junior

🟡 Mid-level

🧐 Analyst

🚫👨‍🎓 No degree required

👻 Ghost score 10%

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The Cigna Group

WebsiteLinkedInAll Job Openings

10,000+ employees

🏥 Healthcare

🛡️ Insurance

Healthcare • Insurance

The Cigna Group is a global health services company that provides medical, dental, pharmacy, behavioral and supplemental insurance products and benefits to individuals, families, employers, brokers, providers and Medicare beneficiaries. It offers employer-sponsored group plans, individual and family plans (including Open Enrollment offerings), Medicare, international health insurance covering more than 200 countries, and digital member services through the myCigna platform (including telehealth and claims management). Its products are delivered through operating subsidiaries such as Cigna Health and Life Insurance Company and other regional affiliates.

📋 Description

• Conduct medical record reviews and accurately abstract diagnosis codes according to Official Coding Guidelines and Conventions, Cigna IFP Coding Guidelines and Best Practices, HHS Protocols, and applicable rules • Use the HHS Risk Adjustment Model to confirm HCC accuracy from abstracted ICD-10-CM diagnosis codes for the correct Benefit Year • Apply longitudinal thinking to identify valid data elements and data-capture opportunities under HHS Risk Adjustment • Perform documentation and data audits to identify risk-adjustment data gaps, inaccuracies, and compliance risks • Support IFP Risk Adjustment programs, including RADV audits and the Supplement Diagnosis submission program • Conduct quality audits of vendor coding partners • Collaborate with team members and matrix partners on coding and Risk Adjustment education for internal and external partners • Coordinate with stakeholders to execute efficient and compliant Risk Adjustment programs • Escalate identified risks and program gaps to management in a timely manner • Develop and implement internal program processes supporting CMS/HHS-compliant programs • Contribute to Cigna IFP Coding Guideline updates and policy determinations as needed

🎯 Requirements

• High school diploma • Prefer 2 years’ experience in one of the listed AHIMA or AAPC coding certifications • Certification such as CPC, CCS-P, CCS-H, RHIT, RHIA, or CRC • Individuals with a certification other than CRC must become CRC certified within 6 months of hire • Experience with medical documentation audits and medical chart reviews • Proficiency with ICD-10-CM coding guidelines and conventions • Familiarity with CMS regulations for Risk Adjustment programs and documentation and coding compliance policies, covering inpatient and outpatient documentation • HCC coding experience preferred • Computer competency with Excel, MS Word, and Adobe Acrobat • Detail-oriented, self-motivated, and excellent organizational skills • Understanding of medical claims submissions preferred • Ability to meet timeline, productivity, and accuracy standards • Ability to communicate effectively across all audiences, verbally and in writing • For home working, cable broadband or fiber optic internet service with at least 10Mbps download/5Mbps upload

🏖️ Benefits

• Remote work option (working at home occasionally or permanently) • Internet service requirement for home working: cable broadband or fiber optic service with at least 10Mbps download/5Mbps upload • Tobacco-free policy; qualifying smoking cessation program may be available where legally permissible • Equal employment opportunity and reasonable accommodation support