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

Primary Functions:

The Quality Review & Audit Analyst is 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 Cigna 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.

Essential Duties:


* Review of medical records with accurate diagnosis code abstraction in accordance with Official Coding Guidelines and Conventions, Cigna 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


* 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,...