Quality Review and Audit Analyst

🔥 41 minutes ago

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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, Cigna, HHS, and applicable coding guidelines. • Use the HHS Risk Adjustment Model to validate Hierarchical Condition Categories identified from ICD-10-CM codes for the correct Benefit Year. • Apply longitudinal review to identify valid data elements and opportunities for risk-adjustment data capture. • Perform documentation and data audits, identify risk-adjustment data gaps, inaccuracies, and compliance risks, and support RADV audits and Supplement Diagnosis submissions. • 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 and escalate risks or gaps to management. • Develop and implement internal processes for CMS/HHS-compliant programs. • Contribute to Cigna IFP Coding Guideline updates and policy determinations.

🎯 Requirements

• High school diploma • 2+ years’ experience in one of the listed coding certifications or Certified Risk Adjustment Coder (CRC) certification • Coding certification from AHIMA or AAPC, including 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 for inpatient and outpatient documentation • HCC coding experience preferred • Computer competency with Excel, MS Word, and Adobe Acrobat • Understanding of medical claims submissions preferred • Ability to meet timeline, productivity, and accuracy standards • Must be detail oriented, self-motivated, and have excellent organization skills • For home working, cable broadband or fiber optic internet service with at least 10Mbps download and 5Mbps upload

🏖️ Benefits

• Annual bonus plan eligibility • Medical, vision, and dental benefits starting on day one • 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 • Tobacco-free policy and smoking cessation program eligibility where applicable