The Risk Adjustment Quality & Review Analyst in IFP brings medical coding and Hierarchical Condition Category expertise to the role, evaluates complex medical conditions, determines compliance of medical documentation, identifies trends, and suggests improvements in data and processes for Continuous Quality Improvement (CQI).
Key Job Functions:
• Conduct medical records reviews with accurate diagnosis code abstraction in accordance with Official Coding Guidelines and Conventions, Cigna IFP Coding Guidelines and Best Practices, HHS Protocols 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 and opportunities for data capture, through the lens of HHS’ Risk Adjustment.
• Perform various documentation and data audits with identification of gaps and/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. Inclusive of Quality Audits for vendor coding partners.
• Collaborate and coordinate with team members and matrix partners to facilitate various aspects of coding and Risk Adjustment education with internal and external partners.
• Coordinate with stake holders to execute efficient and compliant RA programs, raising any identified 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, including contributing 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’ experience in one of the following Coding Certifications by either the American Health Information Management Association (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 months of hire.
Minimum Qualifications
• Experience with medical documentation audits and medical chart reviews and proficiency with ICD-10-CM coding guidelines and conventions
• Familiarity with CMS regulations for Risk Adjustment programs and policies related to documentation and coding compliance, with both Inpatient and Outpatient documentation
• HCC coding experience preferred
• Computer competency with excel, MS Word, Adobe Acrobat
• Must be detail oriented, self-motivated, and have excellent organization skills
• Understanding of medical claims submissions is preferred
• Ability to meet timeline, productivity, and accuracy standards
This role is also anticipated to be eligible to participate in an annual bonus plan.
We want you to be healthy, balanced, and feel secure. That’s why you’ll enjoy a comprehensive range of benefits, with a focus on supporting your whole health. Starting on day one of your employment, you’ll be offered several health-related benefits including medical, vision, dental, and well-being and behavioral health programs. We also offer 401(k) with company match, company paid life insurance, tuition reimbursement, a minimum of 18 days of paid time off per year and paid holidays. For more details on our employee benefits programs, visit Life at Cigna Group .
About Cigna Healthcare
Cigna Healthcare, a division of The Cigna Group, is an advocate for better health through every stage of life. We guide our customers through the health care system, empowering them with the information and insight they need to make the best choices for improving their health and vitality. Join us in driving growth and improving lives.Qualified applicants will be considered without regard to race, color, age, disability, sex, childbirth (including pregnancy) or related medical conditions including but not limited to lactation, sexual orientation, gender identity or expression, veteran or military status, religion, national origin, ancestry, marital or familial status, genetic information, status with regard to public assistance, citizenship status or any other characteristic protected by applicable equal employment opportunity laws.
If you require reasonable accommodation in completing the online application process, please email: SeeYourself@cigna.com for support. Do not email SeeYourself@cigna.com for an update on your application or to provide your resume as you will not receive a response.
The Cigna Group has a tobacco-free policy and reserves the right not to hire tobacco/nicotine users in states where that is legally permissible. Candidates in such states who use tobacco/nicotine will not be considered for employment unless they enter a qualifying smoking cessation program prior to the start of their employment. These states include: Alabama, Alaska, Arizona, Arkansas, Delaware, Florida, Georgia, Hawaii, Idaho, Iowa, Kansas, Maryland, Massachusetts, Michigan, Nebraska, Ohio, Pennsylvania, Texas, Utah, Vermont, and Washington State.
Qualified applicants with criminal histories will be considered for employment in a manner consistent with all federal, state and local ordinances.
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