Individual & Family Plans (IFP) Quality Review and Audit Senior Analyst - Remote - Cigna Healthcare

Summary

Cigna is a health services company committed to providing affordable, simple, and predictable health care solutions to our customers.

The Quality Review and Audit Senior Analystrole supports Cigna's Individual and Family Plan's (IFP) Business Operations' Risk Adjustment and Quality Management program and recognizes the individual who demonstrates an advanced understanding of HHS' Risk Adjustment (RA) programs, and exhibits independent judgment, critical thinking skills, and self-motivation to improve knowledge and skills as related to RA programs.

In addition, this position will be responsible for working with Business Subject Matter Experts (SME), Process Owners, IFP Compliance, IT partners (internal/external), and other technical teams, as required.

Primary Functions:

The Quality Review and Audit Lead Analyst has daily responsibility for coding reviews and audits in support of IFP Risk Adjustment programs, including but not limited to Supplemental Diagnoses, Risk Adjustment Data Validation (RADV) audits, and coder IRR, ensuring compliance with all applicable rules and regulations for execution of HHS' RA programs.

The core duty of this role is to ensure accurate and timely medical code abstraction for Risk Adjustment activities, supporting early identification and correction of errors, and meeting accurate data submission requirements.

Essential Duties include:


* Provides expert reviews of medical records and other medical data to ensure compliance with CMS/HHS guidelines and regulations for Risk Adjustment (RA) in the PPACA marketplace, meeting deadlines successfully.


* Collects, analyzes, and organizes findings with regard to RA data and coding initiatives, collating potential solutions or remedies, and presenting findings and recommendations to peers, leaders, and matrix partners as required.


* Independently generates curriculum and conducts training of junior team members, matrix partners, or external business associates on topics identified by management.


* Reviews current policies and procedures and recommends amendments or changes to current policy to improve compliance.


* Participates in the Supplemental Diagnosis/EDGE submission process to achieve prescribed goals by a prescribed deadline


* Identifies and communicates Continuous Quality Improvement (CQI) opportunities within the IFP RA program.


* Engages in and promotes a collaborative work environment with colleagues, matrix partners, and external business associates, if indicated.


* Supports internal staff and provider partner RA education efforts, as needed, in conjunction with IFP's provider education team.


* Accurately assigns ICD-10-CM diagnosis codes to all applicable risk-adjustable conditions in reviewed medical records, with the ability to identify the associated Hierarchical Condition Category (HCC) codes and associated Service Codes (CPT/HCPCs), as required in support of HHS' RA programs, for the assigned Benefit Y...