Quality Review and Audit Analyst

The Risk Adjustment Quality & Review Analyst in IFP specializes in medical coding and Hierarchical Condition Category expertise, evaluating complex medical conditions, ensuring documentation compliance, and improving data and processes for Continuous Quality Improvement.

Location: United States

Salary: $25–38/hr depending on experience and location, with potential for annual bonus

Responsibilities

• Conduct medical records reviews with accurate diagnosis code abstraction according to coding guidelines and best practices.
• Utilize HHS’ Risk Adjustment Model to confirm accuracy of Hierarchical Condition Categories (HCC).
• Apply longitudinal thinking to identify data elements and opportunities for data capture for risk adjustment.
• Perform documentation and data audits to identify gaps, inaccuracies, and compliance risks, including RADV and Supplement Diagnosis submissions.
• Collaborate with team members and external partners for coding and Risk Adjustment education.
• Coordinate with stakeholders to execute compliant RA programs and address risks or gaps.
• Communicate effectively across all audiences.
• Develop and implement internal program processes ensuring CMS/HHS compliance, including contributing to coding guideline updates.

Requirements

• High school diploma or equivalent.
• At least 2 years’ experience in medical coding or related field.
• Certification in CPC, CCS-P, CCS-H, RHIT, RHIA, or CRC from AHIMA or AAPC.
• Must become CRC certified within 6 months if holding other certifications.

Benefits

• Health benefits including medical, vision, dental, and behavioral health.
• 401(k) plan.
• Company paid life insurance.
• Tuition reimbursement.
• Minimum 18 days paid time off per year and paid holidays.
• Opportunity to participate in an annual bonus plan.

Additional Information

• Remote work possible with internet speed of at least 10Mbps download/5Mbps upload.
• Anticipated hourly rate of $25–38 depending on experience and location.
• The employer is The Cigna Group, which promotes diversity and equal employment opportunity.