Quality Review and Audit Senior Analyst – RADV

Quality Review and Audit Senior Analyst – RADV Job Summary: Responsible for coordination and implementation of daily processes related to IFP Risk Adjustment (RA) programs, including the Risk Adjustment Data Validation (RADV) audit and the Supplement Diagnosis program. Responsible for liaising with the Initial Validation Audit Entity to ensure compliant, efficient, and successful audit processes, including but not limited to file reconciliation and appeals processes. Responsible for coordinating with Quality Mgmt to effectively and compliantly execute daily RA program operations, as identified. Participates in coding reviews of medical documentation for RA programs, as needed. Responsible for communication and reporting of daily productivity and risks associated with IFP RADV audits and other RA programs, as needed, and collaborates with internal educational team to develop necessary curriculum to ensure compliance and program excellence. Contributes to Cigna IFP Coding Guideline updates and policy determinations, and liaises with Matrix Partners, as required, to develop and promote shared goals. The Quality Review and Audit Senior Analyst position recognizes experience in Risk Adjustment Data Validation audits (RADV), Risk Adjustment operations, Risk Adjustment medical record and diagnosis coding excellence, implementation of Quality Improvement processes, and the ability to communicate experience and knowledge to peers, colleagues, and Matrix Partners. Core Responsibilities: Oversight and coordination of daily operations for IFP Risk Adjustment Data Validation (RADV) audits, Support of Supplemental Diagnosis programs, as required Demonstrates comprehensive understanding and proficiency with the Complete Official Code Set, Coding Clinic, and CMS guidelines for IFP code abstraction and medical record compliance Demonstrates comprehensive understanding of RADV Protocols and Compliance Requirements for RA programs, including EDGE Server Business Rules, where applicable Demonstrates ability to coordinate with external partners to execute efficient and compliant programs Demonstrates ability to identify risks or program gaps and communicate effectively to management in a timely manner Demonstrates ability to report productivity, progress, and risks to leadership on a timely basis Develops and implements internal program processes, as required Coordinates with Quality Mgmt to determine priorities and demonstrates ability to prioritize projects to meet deadlines, as determined Demonstrates the ability to remain current on Federal regulations related to diagnosis coding and the HHS Risk Adjustment program, including audit protocols Demonstrates effective communication skills with peers and matrix partners to ensure Continuous Quality Improvement and ensure compliance with all CMS guidelines and regulations Engages in Continuous Quality Improvement (CQI) of IFP programs, as applicable Demonstrates ability to work with external auditors to ensure compliant, efficient, and successful risk adjustment audits, per CMS standards Demonstrates medium proficiency with Microsoft Outlook, Microsoft Excel, Microsoft Word Demonstrates clear and concise professional communication with peers and supervisors, in verbal, telephonic, and written communication Demonstrates knowledge of HIPAA guidelines and protection of PHI in physical and electronic environments Demonstrates the ability to follow verbal and written directions accurately and timely Demonstrates the ability to follow applicable policies and procedures Ability to work independently to accomplish assigned work within the allocated time, meeting deadlines as appropriate Demonstrates ability and willingness to assume other duties as requested, which may or have not be listed in the job description Minimum Qualifications: High School Diploma 5+ year’s Risk Adjustment experience, with certification by either the American Health Information Management Association (AHIMA) or the American Academy of Professional Coders (AAPC) in one of the following certifications: Certified Professional Coder (CPC) Certified Coding Specialist for Providers (CCS-P) Certified Coding Specialist for Hospitals (CCS-H) Registered Health Information Technician (RHIT) Registered Health Information Administrator (RHIA) Certified Risk Adjustment Coder (CRC) certification (within 12 months of hire) Experience with medical audits Proficiency with ICD-10-CM coding and guidelines Familiarity with CMS regulations and polices related to documentation and coding, both with Inpatient and Outpatient documentation HCC coding experience preferred Computer competency with excel, MS Word, Adobe Acrobat Must be detail oriented, self-motivated, and have excellent organization skills Risk Adjustment/CMS knowledge helpful Understanding of medical claims submissions is helpful If you will be working at home occasionally or permanently, the internet connection must be obtained through a cable broadband or fiber optic internet service provider with speeds of at least 10Mbps download/5Mbps upload. For this position, we anticipate offering an annual salary of 58,400 - 97,400 USD / yearly, depending on relevant factors, including experience and geographic location. This role is also anticipated to be eligible to participate in an annual bonus plan. At The Cigna Group, you’ll enjoy a comprehensive range of benefits, with a focus on supporting your whole health. Starting on day one of your employment, you’ll be offered several health-related benefits including medical, vision, dental, and well-being and behavioral health programs. We also offer 401(k), company paid life insurance, tuition reimbursement, a minimum of 18 days of paid time off per year and paid holidays. For more details on our employee benefits programs, click here. About Cigna Healthcare Cigna Healthcare, a division of The Cigna Group, is an advocate for better health through every stage of life. We guide our customers through the health care system, empowering them with the information and insight they need to make the best choices for improving their health and vitality. Join us in driving growth and improving lives. Qualified applicants will be considered without regard to race, color, age, disability, sex, childbirth (including pregnancy) or related medical conditions including but not limited to lactation, sexual orientation, gender identity or expression, veteran or military status, religion, national origin, ancestry, marital or familial status, genetic information, status with regard to public assistance, citizenship status or any other characteristic protected by applicable equal employment opportunity laws. If you need a reasonable accommodation to complete the online application process, please email [email protected] for assistance. Please note that this email inbox is dedicated to accommodation requests only and cannot provide application updates or accept resumes. The Cigna Group has a tobacco-free policy and reserves the right not to hire tobacco/nicotine users in states where that is legally permissible. Candidates in such states who use tobacco/nicotine will not be considered for employment unless they enter a qualifying smoking cessation program prior to the start of their employment. These states include: Alabama, Alaska, Arizona, Arkansas, Delaware, Florida, Georgia, Hawaii, Idaho, Iowa, Kansas, Maryland, Massachusetts, Michigan, Nebraska, Ohio, Pennsylvania, Texas, Utah, Vermont, and Washington State. Qualified applicants with criminal histories will be considered for employment in a manner consistent with all federal, state and local ordinances. Doing something meaningful starts with a simple decision, a commitment to changing lives. At The Cigna Group, we’re dedicated to improving the health and vitality of those we serve. Through our divisions Cigna Healthcare and Evernorth Health Services, we are committed to enhancing the lives of our clients, customers and patients. Join us in driving growth and improving lives.