Quality Review and Audit Senior Analyst - RADV (Remote)

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...