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, 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 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.
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
If you will be working at home occasionally or permanently, the internet connection must be obtained through a cable broadband or fiber optic internet service provider with speeds of at least 10Mbps download/5Mbps upload.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 need a reasonable accommodation to complete the online application process, please email seeyourself@thecignagroup.com for assistance. Please note that this email inbox is dedicated to accommodation requests only and cannot provide application updates or accept resumes.
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.
The Cigna Group is a diversified healthcare company dedicated to improving the health and vitality of those they serve. Through its divisions Cigna Healthcare and Evernorth Health Services, the company provides comprehensive healthcare solutions including insurance products, specialty pharmacy services (through Accredo), and fraud investigation services. The organization serves a complex U.S. employee population exceeding 65,000 and manages relationships with major health plan partners across Medicare, Medicaid, Health Insurance Marketplace, and Commercial segments. The Cigna Group is committed to enhancing the lives of its clients, customers, and patients while driving growth and improving health outcomes.
