QualityReviewandAuditAnalyst

Job Summary: The Quality Review & Audit Senior Analyst (“Analyst”) exhibits expertise in evaluating complex medical documentation for diagnosis code accuracy and compliance in support of the HHS’ Risk Adjustment (RA) program and Risk Adjustment Data Validation (RADV) audits. The Senior Analyst is responsible for all aspects of auditing medical documentation for diagnostic code abstraction, and possesses HHS’ Hierarchical Condition Category (HCC) expertise, evaluating data accuracy and record compliance, executing on audit requirements, and identifying and recommending process improvements within the RA program. Core Responsibilities: • Proficient in assigning accurate ICD-10 diagnosis codes in accordance with Official Coding Guidelines and Conventions, Cigna IFP Coding Guidelines, and HHS’ RADV Protocols Audits accuracy of abstracted diagnostic codes from identified medical record cohorts, evaluating work of peers and/or coding vendor coders, to ensure compliance with quality standards, scoring as appropriate per monthly quality feedback reports or other scoring instrument, as defined per policy. • Performs claims matching and auditing, as required, identifying missing or inaccurate data within RA claims and ensuring compliance with HHS’ RA program protocols. • Leads, trains, or mentors junior team members, as required, sharing expertise in RA programs. • Contributes to execution of Risk Adjustment programs, and other IFP programs, as needed, to ensure accurate and compliant data submissions. • Collaborates and coordinates with stakeholders to facilitate coding and risk adjustment education. • Contributes expertise to creation and maintenance of Coding Guidelines and Best Practices, as needed. • Participates in RADV execution for designated markets, including but not limited to, medical records reviews; subordinate, peer, or vendor coding audits; evaluation and reporting of progress, barriers, or errors; or other tasks as defined in HHS’ RADV Protocols. Minimum Qual