Coding Data Quality Auditor

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.

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.

• 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.                                                                                              

• 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.

• 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.

The typical pay range for this role is:

This pay range represents the base hourly rate or base annual full-time salary for all positions in the job grade within which this position falls.  The actual base salary offer will depend on a variety of factors including experience, education, geography and other relevant factors.  This position is eligible for a CVS Health bonus, commission or short-term incentive program in addition to the base pay range listed above. 
 

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