Note: The job is a remote job and is open to candidates in USA. CVS Health is committed to shaping a more connected and compassionate health experience. The Coding Data Quality Auditor will be responsible for auditing and abstracting medical records to ensure accurate ICD coding in compliance with regulations and internal policies.

Responsibilities

• Responsible for performing audit and abstraction of medical records (provider and/or vendor) to identify and submit 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
• Proficient in abstraction and assignment of accurate medical codes for diagnoses as documented by physicians and other qualified healthcare providers in the office and/or facility setting
• Sound knowledge of coding guidelines and regulations to meet compliance requirements, such as establishing medical necessity
• Identify clinically active vs. historical conditions
• Diagnosis codes must be appropriate, accurate, and supported by clinical documentation in accordance with all State and Federal regulations and internal policies and procedures
• Utilize medical records to ensure support is documented for etiology and manifestations of disease processes
• Adhere to stringent timelines consistent with project deadlines and directives
• Conducts self- process audits to ensure compliance with internal policies and procedures as well as regulatory guidance from CMS, OIG or other Regulatory body
• Required to act in ethical manner at all times as required under HIPAA's Privacy and Security rules to handle patient data with uncompromised adherence to the law
• In depth knowledge of medical terminology and anatomy for all body systems.-Understand the audit process for risk adjustment models
• Performs other related duties as required

Skills

• CPC (Certified Professional Coder) or CCS-P (Certified Coding Specialist-Physician)
• Computer proficiency including experience with Microsoft Office products (Word, Excel, Access, PowerPoint, Outlook, industry standard coding applications)
• Capable of making outbound phone calls and faxes to providers for record retrieval and provider communications regarding audits
• Experience with International Classification of Disease (ICD) codes required
• Minimum of 1 year recent and related experience in medical record documentation review, diagnosis coding, and/or auditing
• Proven ability to support coding judgment and decisions using industry standard evidence and tools
• Proficient in abstraction and assignment of accurate medical codes for diagnoses as documented by physicians and other qualified healthcare providers in the office and/or facility setting
• Sound knowledge of coding guidelines and regulations to meet compliance requirements, such as establishing medical necessity
• Identify clinically active vs. historical conditions
• Diagnosis codes must be appropriate, accurate, and supported by clinical documentation in accordance with all State and Federal regulations and internal policies and procedures
• Utilize medical records to ensure support is documented for etiology and manifestations of disease processes
• Adhere to stringent timelines consistent with project deadlines and directives
• Conducts self- process audits to ensure compliance with internal policies and procedures as well as regulatory guidance from CMS, OIG or other Regulatory body
• Required to act in ethical manner at all times as required under HIPAA's Privacy and Security rules to handle patient data with uncompromised adherence to the law
• In depth knowledge of medical terminology and anatomy for all body systems.-Understand the audit process for risk adjustment models
• Performs other related duties as required
• 3 years recent and related experience in medical record documentation review, diagnosis coding, and/or auditing
• Experience with Medicare and/or Commercial and/or Medicaid Risk Adjustment process and Hierarchical Condition Categories CRC (HCC)CPMA (Certified Professional Medical Auditor), CDEO (Certified Documentation Expert Outpatient) or CPC-I (Certified Professional Coding Instructor) preferred
• Excellent analytical and problem solving skills. Superior communication, organizational, and interpersonal skills
• 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 1-2 years for CPC

Benefits

• This position is eligible for a CVS Health bonus, commission or short-term incentive program in addition to the base pay range listed above.
• This full‑time position is eligible for a comprehensive benefits package designed to support the physical, emotional, and financial well‑being of colleagues and their families.
• The benefits for this position include medical, dental, and vision coverage, paid time off, retirement savings options, wellness programs, and other resources, based on eligibility.

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