Quality Review and Audit Analyst

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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 applicable coding guidelines, Cigna guidelines, HHS protocols, and other rules • Use HHS’ Risk Adjustment Model to confirm the accuracy of HCCs identified from ICD-10-CM diagnosis codes for the correct Benefit Year • Apply longitudinal thinking to identify valid data elements and opportunities for data capture • Perform documentation and data audits, identify gaps, inaccuracies, and compliance risks in risk adjustment data • Support IFP Risk Adjustment programs, including RADV audits and the Supplement Diagnosis submission program • Conduct quality audits for vendor coding partners • Collaborate with team members and matrix partners on coding and Risk Adjustment education • Coordinate with stakeholders to execute efficient and compliant Risk Adjustment programs • Escalate identified risks and program gaps to management promptly • Communicate effectively with all audiences verbally and in writing • Develop and implement internal program processes that ensure CMS/HHS compliance • Contribute to Cigna IFP Coding Guideline updates and policy determinations as needed

🎯 Requirements

• High school diploma • 2+ years’ experience in one of the listed coding certifications/credentials • Current coding certification through AHIMA or AAPC: CPC, CCS-P, CCS-H, RHIT, or RHIA • CRC certification; individuals with another listed certification 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 • Experience with both inpatient and outpatient documentation • HCC coding experience preferred • Computer competency with Excel, MS Word, and Adobe Acrobat • Detail-oriented, self-motivated, and highly organized • Understanding of medical claims submissions preferred • Ability to meet timeline, productivity, and accuracy standards • If working from home, access to cable broadband or fiber optic internet with at least 10Mbps download/5Mbps upload

🏖️ Benefits

• Annual bonus plan eligibility • Medical benefits • Vision benefits • Dental benefits • Well-being and behavioral health programs • 401(k) • Company-paid life insurance • Tuition reimbursement • Minimum of 18 days of paid time off per year • Paid holidays • Leaves of absence • Cable broadband or fiber optic internet service with speeds of at least 10Mbps download/5Mbps upload for home working