Quality Review and Audit Analyst

Job Title: Quality Review and Audit Analyst
Location: Remote
Duration: 02+ Months

Job Summary:

The Risk Adjustment Quality & Review Analyst in Individual and Family Plans (IFP) brings medical coding and Hierarchical Condition Category (HCC) expertise to the role. This position evaluates complex medical conditions, determines compliance with medical documentation, identifies trends, and suggests improvements in data and processes for Continuous Quality Improvement (CQI).

Key Job Functions:

• Conduct medical records reviews with accurate diagnosis code abstraction in accordance with Official Coding Guidelines, IFP Coding Guidelines, HHS Protocols, and any additional applicable rule sets.
• Utilize HHS’ Risk Adjustment Model to confirm the accuracy of Hierarchical Condition Categories (HCC) identified from abstracted ICD-10-CM diagnosis codes for the correct Benefit Year.
• Apply longitudinal thinking to identify valid and appropriate data elements and opportunities for data capture, through the lens of HHS’ Risk Adjustment.
• Perform documentation and data audits to identify gaps and/or inaccuracies in risk adjustment data, and compliance risks in support of IFP Risk Adjustment (RA) programs, including Risk Adjustment Data Validation (RADV) audits and the Supplement Diagnosis submission program, including Quality Audits for vendor coding partners.
• Collaborate and coordinate with team members and matrix partners to facilitate coding and Risk Adjustment education with internal and external partners.
• Coordinate with stakeholders to execute efficient and compliant RA programs, raising any identified risks or program gaps to management promptly.
• Communicate effectively across all audiences (verbal & written).
• Develop and implement internal program processes ensuring CMS/HHS compliant programs, including contributing to IFP Coding Guideline updates and policy determinations as needed.

Education & Experience:

• High school diploma required.
• At least 2 years of experience in one of the following Coding Certifications from either the American Health Information Management Association (AHIMA) or the American Academy of Professional Coders (AAPC):
  • 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)
  • Certified Risk Adjustment Coder (CRC)

Minimum Qualifications:

• Experience with medical documentation audits and medical chart reviews.
• Proficiency with ICD-10-CM coding guidelines and conventions.
• Familiarity with CMS regulations for Risk Adjustment programs and policies related to documentation and coding compliance for both Inpatient and Outpatient documentation.
• HCC coding experience preferred.
• Computer competency with Excel, MS Word, and Adobe Acrobat.
• Detail-oriented, self-motivated, and possess excellent organizational skills.
• Understanding of medical claims submissions is preferred.
• Ability to meet timeline, productivity, and accuracy standards.

 

About Us: Established in 2004, SPECTRAFORCE® is one of the largest and fastest-growing diversity-owned staffing firms in the US. The growth of our company is a direct result of our global client service delivery model that is powered by our state-of-the-art A.I. proprietary talent acquisition platform, robust ISO 9001:2015/ISO 27001 certified processes, and strong and passionate client engaged teams. We have built our business by providing talent and project-based solutions, including Contingent, Permanent, and Statement of Work (SOW) services to over 140 clients in the US, Canada, Puerto Rico, Costa Rica, and India. Key industries that we service include Technology, Financial Services, Life Sciences, Healthcare, Telecom, Retail, Utilities and Transportation. SPECTRAFORCE is built on a concept of “human connection,” defined by our branding attitude of NEWJOBPHORIA®, which is the excitement of bringing joy and freedom to the work lifestyle so our people and clients can reach their highest potential. Learn more at: http://www.spectraforce.com
 
Benefits: SPECTRAFORCE offers ACA compliant health benefits as well as dental, vision, accident, critical illness, voluntary life, and hospital indemnity insurances to eligible employees. Additional benefits offered to eligible employees include commuter benefits, 401K plan with matching, and a referral bonus program. SPECTRAFORCE provides unpaid leave as well as paid sick leave when required by law.

Equal Opportunity Employer: SPECTRAFORCE is an equal opportunity employer and does not discriminate against any employee or applicant for employment because of race, religion, color, sex, national origin, age, sexual orientation, gender identity, genetic information, disability or veteran status, or any other category protected by applicable federal, state, or local laws. Please contact Human Resources at LOA@spectraforce.com if you require reasonable accommodation.
 
California Applicant Notice: SPECTRAFORCE is committed to complying with the California Privacy Rights Act (“CPRA”) effective January 1, 2023; and all data privacy laws in the jurisdictions in which it recruits and hires employees. A Notice to California Job Applicants Regarding the Collection of Personal Information can be located on our website. Applicants with disabilities may access this notice in an alternative format by contacting NAHR@spectraforce.com.
 
LA County, CA Applicant Notice: If you are selected for this position with SPECTRAFORCE, your offer is contingent upon the satisfactory completion of several requirements, including but not limited to, a criminal background check. We consider qualified applicants with arrest or conviction records for employment in accordance with all local ordinances and state laws, including the Los Angeles County Fair Chance Ordinance for Employers (FCO) and the California Fair Chance Act (FCA). The background check assessment will consider whether a criminal history could reasonably have a direct, adverse impact on the job-related safety, security, trust, regulatory compliance, or suitability for this role. Such findings may result in withdrawal of a conditional job offer. 


At SPECTRAFORCE, we are committed to maintaining a workplace that ensures fair compensation and wage transparency in adherence with all applicable state and local laws. This position’s starting pay is: $29.00/hr.