Quality Review and Audit Analyst # : 25-14037

Quality Review and Audit Analyst # : 25-14037

Quality Review and Audit Analyst # : 25-14037

1 day ago Be among the first 25 applicants

This position is 100% remote and candidates can be sourced from across the US as long as they're able to support the EST schedule.

Candidates must have a quiet and private working environment.

Candidates must have a reliable, high-speed internet connection.

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 Supplement 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

• 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.

Top 3 Non-negotiable Skills

HHS / ACA Medical Coding Experience (Commerical coding, Coding Marketplace plans)

Experience with Medical Billing Records

Intermediate Excel Experience

HSS Experience is a nice-to-have

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 be listed in the job description

Seniority level

Seniority level

Mid-Senior level

Employment type

Employment type

Contract

Job function

Job function

Finance and Sales

Industries

IT Services and IT Consulting, Accounting, and Financial Services

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