[Hiring] Coding Data Quality Auditor @CVS Health

Role Description

Responsible for the audit and abstraction of provider and/or vendor medical records to identify ICD codes submitted to the Centers for Medicare & Medicaid Services (CMS). Validates that codes used for risk adjustment processes are accurate, appropriately documented, and compliant with applicable State and Federal regulations and organizational policies and procedures.

• Proven ability to support coding judgment and decisions using industry standard evidence and tools.
• Proficient in abstraction and assignment of accurate medical codes for diagnoses as documented by physicians and other qualified healthcare providers in the office and/or facility setting.
• Sound knowledge of coding guidelines and regulations to meet compliance requirements, such as establishing medical necessity.
• Identify clinically active vs. historical conditions.
• Diagnosis codes must be appropriate, accurate, and supported by clinical documentation in accordance with all State and Federal regulations and internal policies and procedures.
• Utilize medical records to ensure support is documented for etiology and manifestations of disease processes.
• Adhere to stringent timelines consistent with project deadlines and directives.
• Conduct self-process audits to ensure compliance with internal policies and procedures as well as regulatory guidance from CMS, OIG or other Regulatory body.
• 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.
• In depth knowledge of medical terminology and anatomy for all body systems.
• Understand the audit process for risk adjustment models.
• Performs other related duties as required.

Qualifications

• CPC (Certified Professional Coder) or CCS-P (Certified Coding Specialist-Physician).
• Computer proficiency including experience with Microsoft Office products (Word, Excel, Access, PowerPoint, Outlook, industry standard coding applications).
• Capable of making outbound phone calls and faxes to providers for record retrieval and provider communications regarding audits.
• Experience with International Classification of Disease (ICD) codes required.
• Minimum of 1 year recent and related experience in medical record documentation review, diagnosis coding, and/or auditing.

Requirements

• 3 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.
• CRC (HCC), 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.

Education

• AA/AS or equivalent experience.
• Completion of AAPC/AHIMA training program for core credential (CPC, CCS-P) with associated work history/on the job experience equal to approximately 1-2 years for CPC.

Benefits

• Comprehensive benefits package designed to support the physical, emotional, and financial well-being of colleagues and their families.
• Medical, dental, and vision coverage.
• Paid time off.
• Retirement savings options.
• Wellness programs and other resources, based on eligibility.

Pay Range

The typical pay range for this role is: $18.50 - $38.82. This pay range represents the base hourly rate or base annual full-time salary for all positions in the job grade within which this position falls. The actual base salary offer will depend on a variety of factors including experience, education, geography and other relevant factors. This position is eligible for a CVS Health bonus, commission or short-term incentive program in addition to the base pay range listed above.