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Job Details

CVS Health

Analyst Coding Data Quality Auditor (1958740BR)





Kansas, United States

Job Description
Responsible for performing quality inter-rater review audits of medical records coded by internal team (CDQA and Sr CDQA) to ensure the ICD-10 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.
In this position you will have the opportunity to demonstrate proficiency in the following:
- Proven ability to support coding judgment and decisions using industry standard evidence and tools.
- Ability to confidently speak to such evidence across 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.
- Leads dispute resolution.
- Acts as mentor to provide education to internal staff based on audit findings; provides general education on ICD codes as appropriate.
- Effectively communicates the audit process and results to appropriate departments and management.
- Conducts process audits to ensure compliance with internal policies and procedures and existing CMS regulations.
- Identifies and recommends opportunities for process improvements so that productivity and quality goals can be met or exceeded and operational efficiency and final accuracy is achieved.
- 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.
- Must possess high level of dependability and is able to meet coding accuracy and production standards.
- Monitors own work to help ensure quality.
- 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.
-Possesses a genuine interest in improving and promoting quality; demonstrates accuracy and thoroughness and assists others to achieve the same through mentoring and instruction.
- Medical record auditing skills and abstraction expertise. -Serves as the training resource and subject matter expert to vendors, providers and other team members for questions regarding ICD coding and documentation requirements.
-Conducts process audits to ensure compliance with internal policies and procedures as well as regulatory guidance from CMS, OIG or other Regulatory body.
-Expertise in assigning accurate medical codes for diagnoses as documented for physicians and other qualified healthcare providers in the office and/or facility setting.
-Thorough knowledge of coding guidelines and regulations to meet compliance requirements, such as establishing medical necessity.
- In depth knowledge of medical terminology and anatomy for all body systems.
-Understand the audit process for risk adjustment models. -Identify and communicate documentation deficiencies to allow for continuous education opportunities for providers, vendors and peers.
- Expertise in medical documentation, fraud, abuse and penalties for documentation and coding violations based on governmental guidelines.
- Apply AHA Coding Clinic guidance to identify and resolve coding issues.
-Remains current on educational training and requirements including ICD coding, CMS documentation requirements, and State and Federal regulations.
-Performs other related duties as required.

Required Qualifications
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.
Minimum of 5 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 (HCC) required.
CPC (Certified Professional Coder) or CCS-P (Certified Coding Specialist-Physician) and CRC (Certified Risk Adjustment Coder) required

COVID Requirements
CVS Health requires its Colleagues to be fully vaccinated against COVID-19 (including any booster shots if required), where allowable under the law, unless they are approved for a reasonable accommodation based on disability, medical condition, or religious belief that prevents them from being vaccinated.

If you are vaccinated, you are required to have received at least one COVID-19 shot prior to your first day of employment and to provide proof of your vaccination status within the first 10 days of your employment. For the two COVID-19 shot regimen, you will be required to provide proof of your second COVID-19 shot within the first 45 days of your employment. In some states and roles, you may be required to provide proof of full vaccination before you can begin to actively work. Failure to provide timely proof of your COVID-19 vaccination status will result in the termination of your employment with CVS Health.

If you are unable to be fully vaccinated due to disability, medical condition, or religious belief, you will be required to apply for a reasonable accommodation within the first 10 days of your employment in order to remain employed with CVS Health. As a part of this process, you will be required to provide information or documentation about the reason you cannot be vaccinated. In some states and roles, you may be required to have an approved reasonable accommodation before you can begin to actively work. If your request for an accommodation is not approved, then your employment may be terminated.

Preferred Qualifications
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

BA/BS 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 3 years for CPC.
5-8 years encompassing additional credentials and/or application of credentials

Business Overview
At Aetna, a CVS Health company, we are joined in a common purpose: helping people on their path to better health. We are working to transform health care through innovations that make quality care more accessible, easier to use, less expensive and patient-focused. Working together and organizing around the individual, we are pioneering a new approach to total health that puts people at the heart.

We are committed to maintaining a diverse and inclusive workplace. CVS Health is an equal opportunity and affirmative action employer. We do not discriminate in recruiting, hiring or promotion based on race, ethnicity, gender, gender identity, age, disability or protected veteran status. We proudly support and encourage people with military experience (active, veterans, reservists and National Guard) as well as military spouses to apply for CVS Health job opportunities.