Individual & Family Plans (IFP) Quality Review and Audit Manager - Remote - Cigna Healthcare

The Quality Review and Audit Manager (“Manager”) is responsible for the day-to-day management and performance of a team of coding auditors, ensuring delivery of accurate data and meeting of strategic objectives within the Individual and Family Plan’s (IFP) Risk Adjustment Operations.   The Manager will ensure compliance, quality standards, and coding guidelines are followed, while supporting optimal performance on the team, ensuring external coding partners are meeting accuracy standards and applying coding rules and best practices in a compliant manner, developing and delivering any specific coding education to address gaps or deficiencies, and participating in Risk Adjustment activities and projects within the team, as identified by leadership.

Core Responsibilities:

• Develops, supports & executes coding strategies, setting priorities & making recommendations for continuous process & procedure improvement efforts
• Owns, develops & implements coding projects that support data submissions to government oversight agencies, and internal & RADV audits
• Leads a team of ~8 coding auditors ensuring adherence to federal and state regulations, development of compliant coding guidelines, and accurate coding guideline interpretation & application while meeting the highest quality accuracy standards
• Ensures team has necessary tools, resources & support to execute on defined strategy and deliver results
• Leads multiple cross-functional coding initiatives for risk adjustment performance & enhancements
• Works independently to identify issues and trends to facilitate continuous quality improvement; liaising with matrix teams and external coding partners to improve data and outcomes
• Cultivates effective business partnerships to ensure issues are managed proactively and communicated clearly, accurately and effectively with all business partners including external coding partners.
• Coaches, trains and holds team accountable for adherence to coding guidelines, HHS risk adjustment rules & regulations and applicable individual State requirements
• Determines, monitors, manages coding performance metrics & ensuring 95% accuracy of higher along with compliant performance results from external coding partners
• Works closely with internal stakeholders and matrix partners to set and achieve ongoing performance metrics
• Manages key performance indicators & works directly with leadership to report, improve trends, challenges, performance, optimization of technologies, programs, processes, people
• Expert in improving performance, managing change, and problem solving
• Leverages internal resources and independent judgment and discretion to resolve complex coding and data challenges, communicating with team and external coding partners to achieve successful outcomes
• Participates in regularly scheduled feedback and information exchange sessions with key business partners
• Serves as a Subject Matter Expert for project and business development teams
• Leads new platform implementations, developing and maintaining relationships with key external coding partner SMEs to ensure quality output in support of Risk Adjustment and RADV processes
• Transforms complex coding concepts into actionable guidance & outcomes
• Drives removal of roadblocks, project status communication, insights, with resulting business recommendations to leadership

Qualifications:

• Bachelor’s degree or higher, preferred; High School diploma required
• 5+ years minimum coding experience required, with certification by either the American Health Information Management Association (AHIMA) or the American Academy of Professional Coders (AAPC) in one of the following certifications:
• Certified Professional Coder (CPC)
• Certified Coding Specialist for Providers (CCS-P)
• Certified Coding Specialist for Hospitals (CCS-H)
• Registered Health Information Technician (RHIT)
• Registered Health Information Administrator (RHIA)
• Payer experience preferred
• Certified Risk Adjustment Coder (CRC) certification preferred
• Supervisory or management experience required with the ability to effectively manage a team and drive results
• Knowledge of CMS RADV audits, 2 years + of RADV coding experience is preferred
• Familiarity with HHS (PPACA) Risk Adjustment is highly preferred
• Proficiency with CMS/HHS regulations and polices related to documentation and coding, both with Inpatient and Outpatient documentation
• HCC coding experience and Risk Adjustment knowledge strongly preferred
• Strong interpersonal, presentation, and communication skills required, written and verbal
• Strong analytical,