[Remote] Analyst, Coding Data Quality Auditor at CVS Health

Kansas, United States

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Not SpecifiedCompensation

Mid-level (3 to 4 years), Senior (5 to 8 years)Experience Level

Full TimeJob Type

UnknownVisa

HealthcareIndustries

Requirements

Proven ability to support coding judgment and decisions using industry standard evidence and tools
Ability to confidently speak to such evidence across stakeholders with varying knowledge and clinical expertise in either written or verbal forms including communication with clinical or coding staff, federal regulators and vendor coding resources
High level of dependability and ability to meet coding accuracy and production standards
Ability to work independently as well as in a cross-functional role within other teams for collaboration on best practices
Adhere to stringent timelines consistent with project deadlines and directives
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
Medical record auditing skills and abstraction expertise
Expertise in assigning accurate medical codes for diagnoses as documented for physicians and other qualified healthcare providers in the office and/or facility setting
Thorough knowledge of coding guidelines and regulations to meet compliance requirements, such as establishing medical necessity
In-depth knowledge of medical terminology and anatomy for all body systems
Understand the audit process for risk adjustment models
Expertise in medical documentation, fraud, abuse and penalties for documentation and coding violations based on governmental guidelines
Apply AHA Coding Clinic guidance to identify and resolve coding issues
Remains current on educational training and requirements including ICD coding, CMS documentation requirements, and State and Federal regulations

Responsibilities

Performing quality inter-rater review audits of medical records coded by internal team (CDQA and Sr CDQA) to ensure ICD-10 codes submitted to CMS for risk adjustment are appropriate, accurate, and supported by clinical documentation in accordance with State and Federal regulations and internal policies
Leads dispute resolution
Acts as mentor to provide education to internal staff based on audit findings; provides general education on ICD codes as appropriate
Effectively communicates the audit process and results to appropriate departments and management
Conducts process audits to ensure compliance with internal policies and procedures and existing CMS regulations
Identifies and recommends opportunities for process improvements so that productivity and quality goals can be met or exceeded and operational efficiency and final accuracy is achieved
Monitors own work to help ensure quality
Serves as the training resource and subject matter expert to vendors, providers and other team members for questions regarding ICD coding and documentation requirements
Identify and communicate documentation deficiencies to allow for continuous education opportunities for providers, vendors and peers
Performs other related duties as assigned

Skills

ICD-10

Medical Coding

Risk Adjustment

CMS Regulations

Quality Auditing

Inter-rater Review

Clinical Documentation

Audit Process

Dispute Resolution

Process Improvement

Mentoring

Stakeholder Communication

CVS Health

Comprehensive pharmacy and healthcare services

About CVS Health

CVS Health operates a large network of retail pharmacies and walk-in medical clinics across the United States, providing a variety of health-related products and services. Their offerings include prescription medications, over-the-counter health products, and beauty items, as well as pharmacy benefits management and specialty pharmacy services. CVS Health's integrated business model allows them to serve individual consumers, businesses, and communities effectively, with a focus on improving health outcomes and reducing healthcare costs. Unlike many competitors, CVS Health combines pharmacy services with medical care, making it easier for patients to access quality healthcare. The company's goal is to enhance access to healthcare and support individuals in achieving better health.

Woonsocket, Rhode IslandHeadquarters

1963Year Founded

DEBTCompany Stage

Healthcare, Consumer GoodsIndustries

10,001+Employees

Benefits

Health Insurance

Dental Insurance

Vision Insurance

Life Insurance

Disability Insurance

401(k) Retirement Plan

Company Equity

Wellness Program

Professional Development Budget

Paid Vacation

Paid Holidays

Risks

Legal challenges related to opioid prescriptions could harm CVS's reputation and finances.

The DOJ's intervention in a whistleblower lawsuit may increase legal costs for CVS.

The Horizon Organic Milk recall exposes potential vulnerabilities in CVS's supply chain.

Differentiation

CVS Health operates over 9,600 retail pharmacies and 1,100 walk-in clinics nationwide.

The company integrates pharmacy benefits management with specialty pharmacy services for comprehensive care.

CVS Health offers tailored medication plans through personalized medicine and pharmacogenomics.

Upsides

Expansion of telehealth services allows CVS to reach more patients remotely.

Increased consumer interest in wellness boosts demand for CVS's health-related products.

The trend towards value-based care aligns with CVS's integrated healthcare approach.

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