Position: Quality Review and Audit Analyst
Location: 100% Remote
Duration: 03+ Months Contract (Possible extension)
Shift timings: M-F, 7AM-3:30PM or 7:30AM-4PM EST
Responsible for conducting medical record reviews, accurately assigning ICD-10-CM diagnostic codes based on medical record documentation and auditing medical charts for Hierarchical Condition Categories (HCC), as defined by HHS’ Risk Adjustment model. Responsible for performing various documentation and data audits with identification of gaps or inaccuracies in risk adjustment data and identification of compliance risks in support of IFP Risk Adjustment (RA) programs, including the Risk Adjustment Data Validation (RADV) audit and the Supplement Diagnosis submission program. Responsible for collaborating and coordinating, as required, with team members to facilitate coding education with internal and external partners, as well as performing quality reviews of vendor partner coding output.
Contributes to IFP Coding Guideline updates and policy determinations, as needed. The Quality Review and Audit Analyst position recognizes individuals experienced in Risk Adjustment processes, medical record and diagnosis coding excellence, Continuous Quality Improvement (CQI) processes, and the ability to communicate programs and processes to peers, colleagues, and Matrix Partners.
- Review of medical records with accurate diagnosis code abstraction in accordance with Official Coding Guidelines and Conventions, IFP Coding Guidelines and Best Practices, and any application rule set.
- Comprehensive understanding and proficiency with the Complete Official Code Set, Coding Clinic, and CMS guidelines for code abstraction and medical record compliance
- Knowledge and application of Risk Adjustment models when reviewing medical records for code abstraction, with emphasis on HCC identification and CMS compliance for Risk Adjustment programs.
- Demonstration of critical thinking and application of Program regulations and guidelines for Risk Adjustment Data Validation (RADV) audits and Supplemental Diagnosis programs.
- Comprehensive understanding of RADV Protocols and Compliance Requirements for RA programs, including EDGE Server Business Rules, where applicable.
- Coordinates with external partners to execute efficient and compliant programs
- Identifies risks or program gaps and communicate effectively to management in a timely manner
- Demonstrates ability to complete assigned tasks by prescribed deadlines, and meet required productivity standards
- Develops and implements internal program processes, as required
- Remains current on Federal regulations related to diagnosis coding and the HHS Risk Adjustment program, including audit protocols
- Experience with medical audits and medical chart reviews
- Proficiency with ICD-10-CM coding guidelines and conventions
- 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, helpful
- Practices effective communication skills with peers and matrix partners to ensure Continuous Quality Improvement and ensure compliance with all CMS guidelines and regulations;
- Proficiency with Microsoft Outlook, Microsoft Excel, Microsoft Word
- Practices clear, concise, and 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, or other means, as applicable.
- Demonstrates the ability to follow verbal and written directions accurately and timely
- Demonstrates the ability to follow all applicable policies and procedures
- Ability to work independently to accomplish assigned work within the allocated time, meeting deadlines as prescribed
- Demonstrates ability and willingness to assume other duties as requested, which may or have not be listed in the job description
- High School Diploma
- At least 3-5 year’s Risk Adjustment coding 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
- Achieve CRC certification within 6 months of hire, if not currently certified