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

Job Summary:
The Risk Adjustment Quality & Review Analyst in IFP brings medical coding and HierarchicalCondition Category expertise to the role, evaluates complex medical conditions, determinescompliance of medical documentation, identifies trends, and suggests improvements in data andprocesses for Continuous Quality Improvement (CQI).

Key Job Functions:
• Conduct medical records reviews with accurate diagnosis code abstraction in accordance withOfficial Coding Guidelines and Conventions, Cigna IFP Coding Guidelines and Best Practices, HHSProtocols and any additional applicable rule set.
• Utilize HHS' Risk Adjustment Model to confirm accuracy of Hierarchical Condition Categories
(HCC) identified from abstracted ICD-10-CM diagnosis codes for the correct Benefit Year.
• Apply longitudinal thinking to identify all valid and appropriate data elements andopportunities for data capture, through the lens of HHS' Risk Adjustment.
• Perform various documentation and data audits with identification of gaps and/or inaccuracies inrisk 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.

Inclusive of Quality Audits for vendor coding partners.
• Collaborate and coordinate with team members and matrix partners to facilitate various aspectsof coding and Risk Adjustment education with internal and external partners.
• Coordinate with stake holders to execute efficient and compliant RA programs, raising anyidentified risks or program gaps to management in a timely manner.
• Communicate effectively across all audiences (verbal & written).
• Develop and implement internal program processes ensuring CMS/HHS compliant programs, includingcontributing to Cigna IFP Coding Guideline updates and policy determinations, as needed.

Education & Experience:
The Quality Review & Audit Analyst will have a high school diploma and at least 2 years' experiencein one of the following Coding Certifications by either the American Health Information ManagementAssociation (AHIMA) or the American Academy of Professional Coders (AAPC):


* 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

Individuals who have a certification other than the CRC must become CRC certified within 6 monthsof hire.

Minimum Qualifications:
• Experience with medical documentation audits and medical chart reviews and proficiency withICD-10-CM coding guidelines and conventions
• Familiarity with CMS regulations for Risk Adjustment programs and policies related todocumentation and coding compliance, with both Inpatient and Outpatient documentation
• HCC coding exp...