Quality Senior Analyst

At CVS Health, we’re building a world of health around every consumer and surrounding ourselves with dedicated colleagues who are passionate about transforming health care.

As the nation’s leading health solutions company, we reach millions of Americans through our local presence, digital channels and more than 300,000 purpose-driven colleagues – caring for people where, when and how they choose in a way that is uniquely more connected, more convenient and more compassionate. And we do it all with heart, each and every day.

Position Summary

Responsible for conducting complex audits, reviews and assessments of medical records coded by internal teams prior to the submission to the Centers of 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.  Contributes to compliance reporting and documentation, highlighting findings, recommendations, and areas of concern to be delivered to coding resources. 

• Adhere to stringent timelines consistent with project deadlines and directives.
• Demonstrates a strong commitment to enhancing and promoting quality; consistently delivers accurate and thorough work, and supports others in achieving the same standards through effective mentoring and instruction.
• Serves as the training resource and subject matter expert to vendors, providers and other team members for questions regarding ICD coding and documentation requirements.
• Comprehensive knowledge of coding guidelines and regulations to meet compliance requirements, such as establishing medical necessity.
• 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.
• Evidenced knowledge of problem solving and decision making skills

Required Qualifications

• Minimum of 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 (HCC) required.

• Completion of AAPC/AHIMA training program for core credential (CPC, CCS-P) with associated work history/on the job experience equal to approximately 5 years for CPC.

• CPC (Certified Professional Coder) or CCS-P (Certified Coding Specialist-Physician) and CRC (Certified Risk Adjustment Coder) required.

• CPMA (Certified Professional Medical Auditor) or CDEO (Certified Documentation Expert Outpatient) preferred.

Preferred Qualifications

•  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. 
• Experience with Medicare and/or Commercial and/or Medicaid Risk Adjustment process and Hierarchical Condition Categories (HCC) required.
• Expertise in medical documentation, fraud, abuse and penalties for documentation and coding violations based on governmental guidelines.

Education

• Bachelor's degree preferred specialized training/relevant professional qualification, or equivalent work experience.

Anticipated Weekly Hours

40

Time Type

Full time

Pay Range

The typical pay range for this role is:

$46,988.00 - $112,200.00

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. 
 

Our people fuel our future. Our teams reflect the customers, patients, members and communities we serve and we are committed to fostering a workplace where every colleague feels valued and that they belong.

Great benefits for great people

We take pride in our comprehensive and competitive mix of pay and benefits – investing in the physical, emotional and financial wellness of our colleagues and their families to help them be the healthiest they can be. In addition to our competiti