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.

Aetna’s Revenue Integrity team is hiring Senior Coding Data Quality Auditors to support our growing risk adjustment efforts. This role plays a critical part in ensuring coding accuracy and data integrity, directly impacting compliance and financial performance. Ideal candidates will bring a strong understanding of coding standards and auditing practices, along with a passion for continuous improvement. This position will sit within our Regulatory Compliance team and offers the flexibility of working from home.

Position Summary

• Responsible for performing second level quality inter-rater review audits of medical records coded by internal team, as well as external vendor (if applicable) to ensure the ICD 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.
• Proven ability to support coding judgment and decisions using industry standard evidence and tools.
• Ability to confidently speak to such evidence across internal 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.
• Acts as mentor to provide education to internal staff based on audit findings; provides general education on ICD codes as appropriate
• Conducts process audits to ensure compliance with internal policies and procedures and existing CMS regulations.
• 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.
• Possesses a genuine interest in improving and promoting quality; demonstrates accuracy and thoroughness and assists others to achieve the same through mentoring and instruction.
• Conducts process audits to ensure compliance with internal policies and procedures as well as regulatory guidance from CMS, OIG or other Regulatory body.
• Thorough 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 peers.
• Extensive knowledge of medical documentation, fraud, abuse and penalties for documentation and coding violations based on governmental guidelines.
  

Required Qualifications

• Minimum of 3 years recent and related experience in medical record documentation review, diagnosis coding, and/or auditing.
• CPC (Certified Professional Coder) or CCS-P (Certified Coding Specialist-Physician) required.
• 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.

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

• 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 3 years for CPC.

Anticipated Weekly Hours

Time Type

Pay Range

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.

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 competitive wages, our great benefits include:

• Affordable medical plan options, a 401(k) plan (including matching company contributions), and an employee stock purchase plan.

• No-cost programs for all colleagues including wellness screenings, tobacco cessation and weight management programs, confidential counseling and financial coaching.

• Benefit solutions that address the different needs and preferences of our colleagues including paid time off, flexible work schedules, family leave, dependent care resources, colleague assistance programs, tuition assistance, retiree medical access and many other benefits depending on eligibility.

For more information, visit https://jobs.cvshealth.com/us/en/benefits

Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state and local laws.