Job Title: Quality Review and Audit Analyst
Location: Remote
Duration: 3 Months (with a possible extension until December)

Job Summary:

• Responsible for coordination and implementation of daily processes related to IFP Risk Adjustment (RA) programs, including the Risk Adjustment Data Validation (RADV) audit and the Supplemental Diagnosis program.
• Responsible for liaising with the Initial Validation Audit Entity to ensure compliant, efficient, and successful audit processes, including but not limited to file reconciliation and appeals processes.
• Responsible for coordinating with Quality Mgmt. to effectively and compliantly execute daily RA program operations, as identified.
• Participates in coding reviews of medical documentation for RA programs, as needed. Responsible for communication and reporting of daily productivity and risks associated with IFP RADV audits and other RA programs, as needed, and collaborates with internal educational team to develop necessary curriculum to ensure compliance and program excellence.
• Contributes to Client IFP Coding Guideline updates and policy determinations, and liaises with Matrix Partners, as required, to develop and promote shared goals.
• The Quality Review and Audit Senior Analyst position recognizes experience in Risk Adjustment Data Validation audits (RADV), Risk Adjustment operations, Risk Adjustment medical record and diagnosis coding excellence, implementation of Quality Improvement processes, and the ability to communicate experience and knowledge to peers, colleagues, and Matrix Partners.

Core Responsibilities:

• Oversight and coordination of daily operations for IFP Risk Adjustment Data Validation (RADV) audits, Support of Supplemental Diagnosis programs, as required.
• Demonstrates comprehensive understanding and proficiency with the Complete Official Code Set, Coding Clinic, and CMS guidelines for IFP code abstraction and medical record compliance.
• Demonstrates comprehensive understanding of RADV Protocols and Compliance Requirements for RA programs, including EDGE Server Business Rules, where applicable.
• Demonstrates ability to coordinate with external partners to execute efficient and compliant programs.
• Demonstrates ability to identify risks or program gaps and communicate effectively to management in a timely manner.
• Demonstrates ability to report productivity, progress, and risks to leadership on a timely basis.
• Develops and implements internal program processes, as required.
• Coordinates with Quality Mgmt to determine priorities and demonstrates ability to prioritize projects to meet deadlines, as determined.
• Demonstrates the ability to remain current on Federal regulations related to diagnosis coding and the HHS Risk Adjustment program, including audit protocols.
• Demonstrates effective communication skills with peers and matrix partners to ensure Continuous Quality Improvement and ensure compliance with all CMS guidelines and regulations.
• Engages in Continuous Quality Improvement (CQI) of IFP programs, as applicable.
• Demonstrates ability to work with external auditors to ensure compliant, efficient, and successful risk adjustment audits, per CMS standards.
• Demonstrates medium proficiency with Microsoft Outlook, Microsoft Excel, Microsoft Word.
• Demonstrates clear and concise professional communication with peers and supervisors, in verbal, telephonic, and written communication.
• Demonstrates knowledge of HIPAA guidelines and protection of PHI in physical and electronic environments.
• Demonstrates the ability to follow verbal and written directions accurately and timely.
• Demonstrates the ability to follow applicable policies and procedures.
• Ability to work independently to accomplish assigned work within the allocated time, meeting deadlines as appropriate.
• Demonstrates ability and willingness to assume other duties as requested, which may or have not been listed in the job description.

 
Education and Requirements:

• High School Diploma
• 5+ years of Risk Adjustment experience, 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)
• Flexible on less than 5 years or Risk Adjustment experience, if they have HHS/ACA Coding experience
• Certified Risk Adjustment Coder (CRC) certification (within 12 months of hire)
• Experience with medical audits
• Proficiency with ICD-10-CM coding and guidelines
• Familiarity with CMS regulations and polices related to documentation and coding, both with Inpatient and Outpatient documentation
• HCC coding experience preferred
• Computer competency with Excel, MS Word, Adobe Acrobat
• Must be detail-oriented, self-motivated, and have excellent organization skills
• Risk Adjustment/CMS knowledge helpful
• Understanding of medical claims submissions, helpful

 
  
 
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: $ 29.32/hr.