Analyst, Coding Data Quality Audit

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Position Summary

The Coding Data Quality Audit Analyst is responsible for performing second-level quality inter-rater review audits of medical records coded by internal teams, as well as external vendors (if applicable), to ensure that ICD codes submitted to the Centers for Medicare & Medicaid Services (CMS) for risk adjustment purposes are appropriate, accurate, and supported by clinical documentation in accordance with all state and federal regulations, as well as internal policies and procedures.

Job Responsibilities

• Demonstrates the ability to support coding judgments and decisions using industry-standard evidence and tools.
• Confidently communicates supporting evidence to internal stakeholders with varying levels of coding and clinical expertise through both written and verbal communication, including interactions with clinical staff, coding staff, federal regulators, and vendor coding resources.
• Acts as a mentor by providing education to internal staff based on audit findings and offers general education on ICD coding, as appropriate.
• Conducts process audits to ensure compliance with internal policies, procedures, CMS regulations, and guidance from the Office of Inspector General (OIG) and other regulatory bodies.
• Demonstrates the ability to work independently and collaboratively across cross-functional teams to promote best practices.
• Adheres to stringent timelines and project deadlines.
• Demonstrates a genuine commitment to quality improvement, accuracy, and thoroughness while assisting others in achieving the same through mentorship and instruction.
• Maintains thorough knowledge of coding guidelines and regulations to ensure compliance requirements are met, including the establishment of medical necessity.
• Identifies and communicates documentation deficiencies to support ongoing education and development opportunities for peers.
• Maintains extensive knowledge of medical documentation requirements, fraud and abuse regulations, and penalties associated with documentation and coding violations based on governmental guidelines.

Required Qualifications

• Minimum of 3 years of recent, related experience in medical record documentation review, diagnosis coding, and/or auditing.
• Associate degree (AA/AS) or equivalent experience.
• Completion of an AAPC or AHIMA training program for a core credential (CPC or CCS-P), with associated work history and on-the-job experience equivalent to approximately 3 years for CPC certification.
• CPC (Certified Professional Coder) or CCS-P (Certified Coding Specialist-Physician) certification required.

Preferred Qualifications

• CRC (Certified Risk Adjustment Coder) certification required within the first six months.

Education

• Bachelor's degree, Associate degree, or equivalent experience preferred.

Anticipated Weekly Hours

Time Type

Pay Range

The typical pay range for this role is:

This pay range represents the base hourly rate or base annual full-time salary for all positions in the job grade within which this position falls.  The actual base salary offer will depend on a variety of factors including experience, education, geography and other relevant factors.  This position is eligible for a CVS Health bonus, commission or short-term incentive program in addition to the base pay range listed above. 
 

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Great benefits for great people

We take pride in offering a comprehensive and competitive mix of pay and benefits that reflects our commitment to our colleagues and their families.

Additional details about available benefits are provided during the application process and on Benefits Moments.

Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state and local laws.