CVS Health

ICD-10 codes that are submitted to the Centers for Medicare and Medicaid Services (CMS) for the purpose of risk adjustment processes are. CPC (Certified Professional Coder) or CCS-P (Certified Coding Specialist-Physician).. CRC (Certified Risk Adjustment Coder) must be able to obtain within 1 year of employment.. Experience with Medicare and/or Commercial and/or Medicaid Risk. Adjustment process and Hierarchical Condition Categories CRC (HCC).. Professional Medical Auditor), CDEO (Certified Documentation Expert Outpatient) or CPC-I (Certified Professional Coding Instructor) preferred.

quality auditor

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Our Heart At Work Behaviors™ support this purpose. We want everyone who works at CVS Health to feel empowered by the role they play in transforming our culture and accelerating our ability to innovate and deliver solutions to make health care more personal, convenient and affordable.
Position Summary

Responsible for performing quality inter-rater review audits of medical records coded by internal team (CDQA and Sr CDQA) to ensure the
ICD-10 codes that are submitted to the Centers for Medicare and Medicaid Services (CMS) for the purpose of risk adjustment processes are
appropriate, accurate, and supported by clinical documentation in accordance with all State and Federal regulations and internal policies and
procedures. In this position you will have the opportunity to demonstrate proficiency in the following:
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.
Leads dispute resolution.
Act 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.
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.
Must possess high level of dependability and is able to meet coding accuracy and production standards.
Monitors own work to help ensure quality.
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.
Possesses a genuine interest in improving and promoting quality; demonstrates accuracy and thoroughness and assists others to achieve the same through mentoring and instruction.
Medical record auditing skills and abstraction expertise.
Serves as the training resource and subject matter expert to vendors, providers and other team members for questions regarding ICD coding and documentation requirements.
Conducts process audits to ensure compliance with internal policies and procedures as well as regulatory guidance from CMS, OIG or other Regulatory body.
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.
Identify and communicate documentation deficiencies to allow for continuous education opportunities for providers, vendors and peers.
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.
Performs other related duties as required.

Required Qualifications
CPC (Certified Professional Coder) or CCS-P (Certified Coding Specialist-Physician).
CRC (Certified Risk Adjustment Coder) must be able to obtain within 1 year of employment.
Computer proficiency including experience with Microsoft Office products (Word, Excel, Access).
PowerPoint, Outlook, industry standard coding applications). Experience with International Classification of Disease (ICD) codes required.
Minimum of 2 years recent and related experience in medical record documentation review, diagnosis coding, and/or auditing.

Preferred Qualifications
5 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
Completion of AAPC/AHIMA training program for core credential (CPC, CCS-P) with associated work history/on the job experience equal to approximately 2 years for CPC.
Pay Range
The typical pay range for this role is:
$18.50 - $31.72
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.

In addition to your compensation, enjoy the rewards of an organization that puts our heart into caring for our colleagues and our communities. The Company offers a full range of medical, dental, and vision benefits. Eligible employees may enroll in the Company’s 401(k) retirement savings plan, and an Employee Stock Purchase Plan is also available for eligible employees. The Company provides a fully-paid term life insurance plan to eligible employees, and short-term and long term disability benefits. CVS Health also offers numerous well-being programs, education assistance, free development courses, a CVS store discount, and discount programs with participating partners. As for time off, Company employees enjoy Paid Time Off (“PTO”) or vacation pay, as well as paid holidays throughout the calendar year. Number of paid holidays, sick time and other time off are provided consistent with relevant state law and Company policies.

For more detailed information on available benefits, please visit jobs.CVSHealth.com/benefits
CVS Health requires certain colleagues to be fully vaccinated against COVID-19 (including any booster shots if required), where allowable under the law, unless they are approved for a reasonable accommodation based on disability, medical condition, religious belief, or other legally recognized reasons that prevents them from being vaccinated.
You are required to have received at least one COVID-19 shot prior to your first day of employment and to provide proof of your vaccination status or apply for a reasonable accommodation within the first 10 days of your employment. Please note that in some states and roles, you may be required to provide proof of full vaccination or an approved reasonable accommodation before you can begin to actively work.
CVS Health is committed to recruiting, hiring, developing, advancing, and retaining individuals with disabilities. As such, we strive to provide equal access to the benefits and privileges of employment, including the provision of a reasonable accommodation to perform essential job functions. CVS Health can provide a request for a reasonable accommodation, including a qualified interpreter, written information in other formats, translation or other services through ColleagueRelations@CVSHealth.com If you have a speech or hearing disability, please call 7-1-1 to utilize Telecommunications Relay Services (TRS). We will make every effort to respond to your request within 48 business hours and do everything we can to work towards a solution.

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