Quality Review and Audit Analyst

Immediate need for a talented Quality Review and Audit Analyst. This is a 03 months contract opportunity with long-term potential and is located in U.S(Remote). Please review the job description below and contact me ASAP if you are interested.

Job ID: 25-86884

Pay Range: $27 - $28.50/hour.  Employee benefits include, but are not limited to, health insurance (medical, dental, vision), 401(k) plan, and paid sick leave (depending on work location).

Key Responsibilities:

• Utilize HHS’ Risk Adjustment Model to confirm accuracy of Hierarchical Condition Categories (HCC)identified from abstracted ICD-10-CM diagnosis codes for the correct Benefit Year.
• Apply longitudinal thinking to identify all valid and appropriate data elements and opportunities for datacapture, through the lens of HHS’ Risk Adjustment.
• Perform various documentation and data audits with identification of gaps and/or inaccuracies in riskadjustment data and identification of compliance risks in support of IFP Risk Adjustment (RA) programs,including the Risk Adjustment Data Validation (RADV) audit and the Supplement Diagnosis submissionprogram. Inclusive of Quality Audits for vendor coding partners.
• Collaborate and coordinate with team members and matrix partners to facilitate various aspects of codingand Risk Adjustment education with internal and external partners.
• Coordinate with stake holders to execute efficient and compliant RA programs, raising any identified risksor program gaps to management in a timely manner.
• Communicate effectively across all audiences (verbal & written).
• Develop and implement internal program processes ensuring CMS/HHS compliant programs, includingcontributing to Client IFP Coding Guideline updates and policy determinations, as needed

Key Requirements and Technology Experience: 

• 5 years HCC coding experience
• CPC or CRC coding certification
• Risk Adjustment experience
• Risk Adjustment data validation experience
• Medical claims or medical records auditing experience
• HCC/Risk Adjustment experience (2 years )
• Microsoft Office Experience
• Excellent Written and Verbal communication skills
• Experience with medical documentation audits and medical chart reviews and proficiency with ICD-10-CMcoding guidelines and conventions
• Familiarity with CMS regulations for Risk Adjustment programs and policies related to documentation andcoding compliance, with both 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
• Understanding of medical claims submissions is preferred
• Ability to meet timeline, productivity, and accuracy standards
• Experience working in a remote environment
• Excellent and clear written and verbal communication skills

Our client is a leading Health Insurance Industry, and we are currently interviewing to fill this and other similar contract positions. If you are interested in this position, please apply online for immediate consideration.

Pyramid Consulting, Inc. provides equal employment opportunities to all employees and applicants for employment and prohibits discrimination and harassment of any type without regard to race, color, religion, age, sex, national origin, disability status, genetics, protected veteran status, sexual orientation, gender identity or expression, or any other characteristic protected by federal, state or local laws.

By applying to our jobs you agree to receive calls, AI-generated calls, text messages, or emails from Pyramid Consulting, Inc. and its affiliates, and contracted partners. Frequency varies for text messages. Message and data rates may apply. Carriers are not liable for delayed or undelivered messages. You can reply STOP to cancel and HELP for help. You can access our privacy policy