Coding Data Quality Auditor

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About the role

We’re building a world of health around every individual — shaping a more connected, convenient and compassionate health experience. At CVS Health®, you’ll be surrounded by passionate colleagues who care deeply, innovate with purpose, hold ourselves accountable and prioritize safety and quality in everything we do. Join us and be part of something bigger – helping to simplify health care one person, one family and one community at a time. Position Summary Responsible for the audit and abstraction of provider and/or vendor medical records to identify ICD codes submitted to the Centers for Medicare & Medicaid Services (CMS). Validates that codes used for risk adjustment processes are accurate, appropriately documented, and compliant with applicable State and Federal regulations and organizational policies and procedures. • Proven ability to support coding judgment and decisions using industry standard evidence and tools. • Proficient in abstraction and assignment of accurate medical codes for diagnoses as documented by physicians and other qualified healthcare providers in the office and/or facility setting.  • Sound knowledge of coding guidelines and regulations to meet compliance requirements, such as establishing medical necessity.  • Identify clinically active vs. historical conditions. • Diagnosis codes must be appropriate, accurate, and supported by clinical documentation in accordance with all State and Federal regulations and internal policies and procedures. • Utilize medical records to ensure support is documented for etiology and manifestations of disease processes.   • Adhere to stringent timelines consistent with project deadlines and directives. • Conducts self- process audits to ensure compliance with internal policies and procedures as well as regulatory guidance from CMS, OIG or other Regulatory body. • Required to act in ethical manner at all times as required under HIPAA's Privacy and Security rules to handle patient data with uncompromised adherence to the law. • In depth knowledge of medical terminology and anatomy for all body systems.-Understand the audit process for risk adjustment models. • Performs other related duties as required.   Required Qualifications • CPC (Certified Professional Coder) or CCS-P (Certified Coding Specialist-Physician). • Computer proficiency including experience with Microsoft Office products (Word, Excel, Access, PowerPoint, Outlook, industry standard coding applications). • Capable of making outbound phone calls and faxes to providers for record retrieval and provider communications regarding audits. • Experience with International Classification of Disease (ICD) codes required. • Minimum of 1 year recent and related experience in medical record documentation review, diagnosis coding, and/or auditing.                                                                                                 Preferred Qualifications • 3 years recent and related experience in medical record documentation review, diagnosis coding, and/or auditing. • Experience with Medicare and/or Commercial and/or Medicaid Risk Adjustment process and Hierarchical Condition Categories CRC (HCC)CPMA (Certified Professional Medical Auditor), CDEO (Certified Documentation Expert Outpatient) or CPC-I (Certified Professional Coding Instructor) preferred. • Excellent analytical and problem solving skills. Superior communication, organizational, and interpersonal skills.     Education • AA/AS or equivalent experience • Completion of AAPC/AHIMA training program for core credential (CPC, CCS-P) with associated work history/on the job experience equal to approximately 1-2 years for CPC. Anticipated Weekly Hours 40 Time Type Full time Pay Range The typical pay range for this role is: $18.50 - $

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