Summary

Cigna is a health services company committed to providing affordable, simple, and predictable health care solutions to our customers. The Quality Review and Audit Senior Analyst role supports Cigna's Individual and Family Plan’s (IFP) Business Operations’ Risk Adjustment and Quality Management program and recognizes the individual who demonstrates an advanced understanding of HHS’ Risk Adjustment (RA) programs, and exhibits independent judgment, critical thinking skills, and self-motivation to improve knowledge and skills as related to RA programs.  In addition, this position will be responsible for working with Business Subject Matter Experts (SME), Process Owners, IFP Compliance, IT partners (internal/external), and other technical teams, as required. 

Primary Functions:

The Quality Review and Audit Lead Analyst has daily responsibility for coding reviews and audits in support of IFP Risk Adjustment programs, including but not limited to Supplemental Diagnoses, Risk Adjustment Data Validation (RADV) audits, and coder IRR, ensuring compliance with all applicable rules and regulations for execution of HHS’ RA programs. The core duty of this role is to ensure accurate and timely medical code abstraction for Risk Adjustment activities, supporting early identification and correction of errors, and meeting accurate data submission requirements.

Essential Duties include:

Provides expert reviews of medical records and other medical data to ensure compliance with CMS/HHS guidelines and regulations for Risk Adjustment (RA) in the PPACA marketplace, meeting deadlines successfully.Collects, analyzes, and organizes findings with regard to RA data and coding initiatives, collating potential solutions or remedies, and presenting findings and recommendations to peers, leaders, and matrix partners as required.Independently generates curriculum and conducts training of junior team members, matrix partners, or external business associates on topics identified by management.Reviews current policies and procedures and recommends amendments or changes to current policy to improve compliance.Participates in the Supplemental Diagnosis/EDGE submission process to achieve prescribed goals by a prescribed deadlineIdentifies and communicates Continuous Quality Improvement (CQI) opportunities within the IFP RA program.Engages in and promotes a collaborative work environment with colleagues, matrix partners, and external business associates, if indicated.Supports internal staff and provider partner RA education efforts, as needed, in conjunction with IFP’s provider education team.Accurately assigns ICD-10-CM diagnosis codes to all applicable risk-adjustable conditions in reviewed medical records, with the ability to identify the associated Hierarchical Condition Category (HCC) codes and associated Service Codes (CPT/HCPCs), as required in support of HHS’ RA programs, for the assigned Benefit Year.Adheres to all Cigna, CMS, and other entity guidelines, regulations, and rules for accurate medical diagnosis coding and Risk Adjustment program execution.Maintains all appropriate certifications, including CEUs as required, for continuous coding certification in good standing with the accrediting organizationDevelops and implements coding education curriculum for internal coders, vendor coding teams, and provider partners, as appropriate, to improve understanding of, and execution of, coding guidelinesStays current on Federal regulations related to diagnosis coding and the HHS Risk Adjustment programConduct audits of IFP and Vendor coding results to ensure coding accuracy and compliance standards are maintained, including Inter Rater Reliability (IRR) processesInterprets analysis of complex coding patterns, trends, and scenarios, with ability to present findings to peers & matrix partners as required

Required Competencies – Skills – Demonstrated Knowledge:

Comprehensive understanding and proficiency with the Complete Official Code Set, Coding Clinic, and CMS guidelines for ICD-10-CM code abstraction and Cigna IFP’s Coding Guidelines and Best PracticesExperience with continuous process improvement tools, Six Sigma preferredAbility to facilitate meetings, teach others, and see projects through to completionDemonstrated ability to lead, coach, and drive changeStrong interpersonal, presentation, and communication skills requiredDemonstrated ability to work with a high level of independence with strong collaboration and relationship management skills requiredAbility to work independently to accomplish assigned work within the allocated time, meeting deadlinesProblem-solving capability with creation and successful implementation of process improvement plansAbility to manage frequent change, adapt to a dynamic regulatory environment, and lead teams in adjusting activities, as appropriateProven ability to manage multiple concurrent tasks and manage competing priorities, maintaining alignment with leadership and team objectives Ability to adhere to CMS and Cigna compliance requirements for Risk Adjustment codingDemonstrates clear, concise, professional, and effective communication skills with peers and matrix partners to facilitate quality application of all guidelines, regulations, and programs; Engages in Continuous Quality Improvement (CQI) of IFP programs, as applicableDemonstrates ability to work with external auditors to ensure compliant, efficient, and successful risk adjustment audits, per CMS standardsProven ability to prioritize projects to meet deadlinesProficiency with the Microsoft suite of produces, specifically Microsoft Excel and Microsoft WordUnderstands HIPAA guidelines and protection of PHI in physical and electronic environmentsAbility to follow verbal and/or written direction and all applicable policies and procedures, accurately and timelyWillingness to assume other duties as requested, which may or have not be listed in the job description

Minimum QualificationsCollege Education preferred/High School diploma requiredMust have five year’s coding experience with Certified Professional Coder (CPC) or equivalent certification by either the American Health Information Management Association (AHIMA) or the American Academy of Professional Coders (AAPC).Experience with continuous process improvement tools, Six Sigma preferredAbility to facilitate meetings, teach others, and see projects through to completionDemonstrated ability to lead, coach, and drive changeStrong interpersonal, presentation, and communication skills requiredDemonstrated ability to work with a high level of independence with strong collaboration and relationship management skills requiredDemonstrated ability to lead, coach, and drive changeCertified Risk Adjustment Coder (CRC) certification preferred, or required within 12 months of hireProficiency with ICD-10-CM coding and guidelinesProficiency with CMS/HHS regulations and polices related to documentation and coding, both with Inpatient and Outpatient documentationHCC coding experience and Risk Adjustment knowledge strongly preferredComputer competency with Excel, MS Word, Adobe Acrobat, (Access preferred)Must be detail oriented, self-motivated, and have excellent organization and communication skills

If you will be working at home occasionally or permanently, the internet connection must be obtained through a cable broadband or fiber optic internet service provider with speeds of at least 10Mbps download/5Mbps upload.

For this position, we anticipate offering an annual salary of 56,600 - 94,300 USD / yearly, depending on relevant factors, including experience and geographic location.

This role is also anticipated to be eligible to participate in an annual bonus plan.

We want you to be healthy, balanced, and feel secure. That’s why you’ll enjoy a comprehensive range of benefits, with a focus on supporting your whole health. Starting on day one of your employment, you’ll be offered several health-related benefits including medical, vision, dental, and well-being and behavioral health programs. We also offer 401(k) with company match, company paid life insurance, tuition reimbursement, a minimum of 18 days of paid time off per year and paid holidays. For more details on our employee benefits programs, visit Life at Cigna Group.

About Cigna Healthcare

Cigna Healthcare, a division of The Cigna Group, is an advocate for better health through every stage of life. We guide our customers through the health care system, empowering them with the information and insight they need to make the best choices for improving their health and vitality. Join us in driving growth and improving lives.

Qualified applicants will be considered without regard to race, color, age, disability, sex, childbirth (including pregnancy) or related medical conditions including but not limited to lactation, sexual orientation, gender identity or expression, veteran or military status, religion, national origin, ancestry, marital or familial status, genetic information, status with regard to public assistance, citizenship status or any other characteristic protected by applicable equal employment opportunity laws.

If you require reasonable accommodation in completing the online application process, please email: SeeYourself@cigna.com for support. Do not email SeeYourself@cigna.com for an update on your application or to provide your resume as you will not receive a response.

The Cigna Group has a tobacco-free policy and reserves the right not to hire tobacco/nicotine users in states where that is legally permissible. Candidates in such states who use tobacco/nicotine will not be considered for employment unless they enter a qualifying smoking cessation program prior to the start of their employment. These states include: Alabama, Alaska, Arizona, Arkansas, Delaware, Florida, Georgia, Hawaii, Idaho, Iowa, Kansas, Maryland, Massachusetts, Michigan, Nebraska, Ohio, Pennsylvania, Texas, Utah, Vermont, and Washington State.

Qualified applicants with criminal histories will be considered for employment in a manner consistent with all federal, state and local ordinances.