[Hiring] Coding Data Quality Auditor @CVS Health

Role Description

Responsible for performing audit and abstraction of medical records (provider and/or vendor) to identify and submit 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.
• 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.

Qualifications

• Minimum of 1 year recent and related experience in medical record documentation review, diagnosis coding, and/or auditing.
• CPC (Certified Professional Coder) or CCS-P (Certified Coding Specialist-Physician) required.
• Computer proficiency including experience with Microsoft Office products (Word, Excel, Access, PowerPoint, Outlook, industry standard coding applications).
• Experience with International Classification of Disease (ICD) codes required.

Requirements

• CRC (Certified Risk Adjustment Coder) preferred.
• Experience with Medicare and/or Commercial and/or Medicaid Risk Adjustment process and Hierarchical Condition Categories (HCC) preferred.
• 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.