Quality Review and Audit Analyst

HireTalent

Franklin, TN

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JOB DETAILS

SKILLS

Adobe Acrobat, Analysis Skills, Best Practices, Certified Coding Specialist (CCS), Certified Professional Coder (CPC), Communication Skills, Content Management Systems (CMS), Data Quality, Department of Health and Human Services, Detail Oriented, Documentation, Health Information Management, High School Diploma, Hospital, ICD-10, Medical Coding, Medical Conditions, Medical Records, Microsoft Excel, Microsoft Word, Organizational Skills, Outpatient Care, Patient Care, Patient Charts, Process Improvement, Quality Management, Registered Health Information Administrator (RHIA), Registered Health Information Technician (RHIT), Regulations, Risk, Risk Analysis, Risk Modeling, Systems/Internals Programming, Time Management, Trend Analysis, Vendor/Supplier Evaluation

LOCATION

Franklin, TN

POSTED

1 day ago

Role Description/ Role Assessment

Proposed *** Role Quality Review and Audit Analyst
Business Unit US Individual
Manager Name Melissa Maes Nicholas
New/Existing Role? Existing
Individual Contributor/Manager? Individual Contributor

Job Purpose/Role Description
Job Summary:

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, *** 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 *** 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):

o Certified Professional Coder (CPC)
o Certified Coding Specialist for Providers (CCS-P)
o Certified Coding Specialist for Hospitals (CCS-H)
o Registered Health Information Technician (RHIT)
o Registered Health Information Administrator (RHIA)
o Certified Risk Adjustment Coder (CRC) certification

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

3 Non-Negotiable Skills:
- HCC Coding Exp (2 yrs)
- Certified Professional Coder (CPC or CCS)
- Microsoft Office Skills (Medium)

About the Company

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