Coding Data Quality Auditor Analyst

CVS Health

21h • $21 - $37

About The Position

We’re building a world of health around every individual — shaping a more connected, convenient and compassionate health experience. At CVS Health®, you’ll be surrounded by passionate colleagues who care deeply, innovate with purpose, hold ourselves accountable and prioritize safety and quality in everything we do. Join us and be part of something bigger – helping to simplify health care one person, one family and one community at a time. Position Summary Responsible for performing second level quality inter-rater review audits of medical records coded by internal team, as well as external vendor (if applicable) to ensure the ICD codes that are submitted to the Centers for Medicare and Medicaid Services (CMS) for the purpose of risk adjustment processes are appropriate, accurate, and supported by clinical documentation in accordance with all State and Federal regulations and internal policies and procedures. Proven ability to support coding judgment and decisions using industry standard evidence and tools. Ability to confidently speak to such evidence across internal 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. Acts as mentor to provide education to internal staff based on audit findings; provides general education on ICD codes as appropriate Conducts process audits to ensure compliance with internal policies and procedures and existing CMS regulations. 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. Possesses a genuine interest in improving and promoting quality; demonstrates accuracy and thoroughness and assists others to achieve the same through mentoring and instruction. Conducts process audits to ensure compliance with internal policies and procedures as well as regulatory guidance from CMS, OIG or other Regulatory body. Thorough knowledge of coding guidelines and regulations to meet compliance requirements, such as establishing medical necessity. Identify and communicate documentation deficiencies to allow for continuous education opportunities for peers. Extensive knowledge of medical documentation, fraud, abuse and penalties for documentation and coding violations based on governmental guidelines.

Requirements

• Minimum of 3 years recent and related experience in medical record documentation review, diagnosis coding, and/or auditing.
• Completion of AAPC/AHIMA, (American Academy of Professional Coders/ American Health Information Management Association), training program for core credential (CPC, CCS-P) with associated work history/on the job experience equal to approximately 3 years for CPC.
• CPC (Certified Professional Coder) or CCS-P (Certified Coding Specialist-Physician) required.
• CRC (Certified Risk Adjustment Coder) required within the first six months.

Nice To Haves

• 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.

Responsibilities

• Responsible for performing second level quality inter-rater review audits of medical records coded by internal team, as well as external vendor (if applicable) to ensure the ICD codes that are submitted to the Centers for Medicare and Medicaid Services (CMS) for the purpose of risk adjustment processes are appropriate, accurate, and supported by clinical documentation in accordance with all State and Federal regulations and internal policies and procedures.
• Proven ability to support coding judgment and decisions using industry standard evidence and tools.
• Ability to confidently speak to such evidence across internal 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.
• Acts as mentor to provide education to internal staff based on audit findings; provides general education on ICD codes as appropriate
• Conducts process audits to ensure compliance with internal policies and procedures and existing CMS regulations.
• 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.
• Possesses a genuine interest in improving and promoting quality; demonstrates accuracy and thoroughness and assists others to achieve the same through mentoring and instruction.
• Conducts process audits to ensure compliance with internal policies and procedures as well as regulatory guidance from CMS, OIG or other Regulatory body.
• Thorough knowledge of coding guidelines and regulations to meet compliance requirements, such as establishing medical necessity.
• Identify and communicate documentation deficiencies to allow for continuous education opportunities for peers.
• Extensive knowledge of medical documentation, fraud, abuse and penalties for documentation and coding violations based on governmental guidelines.

Benefits

• Affordable medical plan options, a 401(k) plan (including matching company contributions), and an employee stock purchase plan.
• No-cost programs for all colleagues including wellness screenings, tobacco cessation and weight management programs, confidential counseling and financial coaching.
• Benefit solutions that address the different needs and preferences of our colleagues including paid time off, flexible work schedules, family leave, dependent care resources, colleague assistance programs, tuition assistance, retiree medical access and many other benefits depending on eligibility.

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Education Level: Associate degree