We’re building a world of health around every individual — shaping a more connected, convenient and compassionate health experience. At CVS Health®, you’ll be surrounded by passionate colleagues who care deeply, innovate with purpose, hold ourselves accountable and prioritize safety and quality in everything we do. Join us and be part of something bigger – helping to simplify health care one person, one family and one community at a time.
Position Summary
Responsible for performing quality inter-rater review audits of medical records coded by internal team (CDQA and Sr CDQA) to ensure the ICD-10 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.
In this position you will have the opportunity to demonstrate proficiency in the following:
- Proven ability to support coding judgment and decisions using industry standard evidence and tools.
- Ability to confidently speak to such evidence across stakeholders with varying knowledge and clinical expertise in either written or verbal forms including communication with clinical or coding staff, federal regulators and vendor coding resources.
- Leads dispute resolution.
- Acts as mentor to provide education to internal staff based on audit findings; provides general education on ICD codes as appropriate.
- Effectively communicates the audit process and results to appropriate departments and management.
- Conducts process audits to ensure compliance with internal policies and procedures and existing CMS regulations.
- Identifies and recommends opportunities for process improvements so that productivity and quality goals can be met or exceeded and operational efficiency and final accuracy is achieved.
- Ability to work independently as well as in a cross functional role within other teams for collaboration on best practices.
- Adhere to stringent timelines consistent with project deadlines and directives.
- Must possess high level of dependability and is able to meet coding accuracy and production standards.
- Monitors own work to help ensure quality.
- 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.
- Possesses a genuine interest in improving and promoting quality; demonstrates accuracy and thoroughness and assists others to achieve the same through mentoring and instruction.
- Medical record auditing skills and abstraction expertise.
- Serves as the training resource and subject matter expert to vendors, providers and other team members for questions regarding ICD coding and documentation requirements.
- Conducts process audits to ensure compliance with internal policies and procedures as well as regulatory guidance from CMS, OIG or other Regulatory body.
- Expertise in assigning accurate medical codes for diagnoses as documented for physicians and other qualified healthcare providers in the office and/or facility setting.
- Thorough knowledge of coding guidelines and regulations to meet compliance requirements, such as establishing medical necessity.
- In depth knowledge of medical terminology and anatomy for all body systems
- Understand the audit process for risk adjustment models.
- Identify and communicate documentation deficiencies to allow for continuous education opportunities for providers, vendors and peers.
- Expertise in medical documentation, fraud, abuse and penalties for documentation and coding violations based on governmental guidelines.
- Apply AHA Coding Clinic guidance to identify and resolve coding issues.
- Remains current on educational training and requirements including ICD coding, CMS documentation requirements, and State and Federal regulations.
- Performs other related duties as required
Required Qualifications
- Computer proficiency including experience with Microsoft Office products (Word, Excel, Access, PowerPoint, Outlook, industry standard coding applications).
- Experience with International Classification of Disease (ICD) codes required.
- Minimum of 5 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 (HCC) required.
- CPC (Certified Professional Coder) or CCS-P (Certified Coding Specialist-Physician) AND CRC (Certified Risk Adjustment Coder) required
Preferred Qualifications
- 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
- Completion of AAPC/AHIMA training program for core credential (CPC, CCS-P) with associated work history/on the job experience equal to approximately 3 years for CPC.
- 5-8 years encompassing additional credentials and/or application of credentials.
Education
- BA/BS or equivalent experience.
Anticipated Weekly Hours
40Time Type
Full timePay Range
The typical pay range for this role is:
$21.10 - $44.99This pay range represents the base hourly rate or base annual full-time salary for all positions in the job grade within which this position falls. The actual base salary offer will depend on a variety of factors including experience, education, geography and other relevant factors. This position is eligible for a CVS Health bonus, commission or short-term incentive program in addition to the base pay range listed above.
Our people fuel our future. Our teams reflect the customers, patients, members and communities we serve and we are committed to fostering a workplace where every colleague feels valued and that they belong.
Great benefits for great people
We take pride in offering a comprehensive and competitive mix of pay and benefits that reflects our commitment to our colleagues and their families.
Additional details about available benefits are provided during the application process and on Benefits Moments.
Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state and local laws.
Skills Required
- Proficiency with Microsoft Word, Excel, Access, PowerPoint, Outlook and industry standard coding applications.
- Experience with International Classification of Disease (ICD/ICD-10) codes.
- Minimum of 5 years recent and related experience in medical record documentation review, diagnosis coding, and/or auditing.
- Experience with Medicare, Commercial, and/or Medicaid Risk Adjustment processes and Hierarchical Condition Categories (HCC).
- CPC (Certified Professional Coder) or CCS-P (Certified Coding Specialist-Physician) AND CRC (Certified Risk Adjustment Coder) certifications.
- Adherence to HIPAA Privacy and Security rules when handling patient data.
- BA/BS degree or equivalent experience.
- CPMA, CDEO, or CPC-I certifications.
- Completion of AAPC/AHIMA training program for core credential with associated work history/on-the-job experience.
- 5-8 years encompassing additional credentials and/or application of credentials.
- Excellent analytical and problem solving skills.
- Superior communication, organizational, and interpersonal skills.
CVS Health Compensation & Benefits Highlights
The following summarizes recurring compensation and benefits themes identified from responses generated by popular LLMs to common candidate questions about CVS Health and has not been reviewed or approved by CVS Health.
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Healthcare Strength — Health coverage includes medical, dental, and vision with HSA-eligible options, free preventive care, virtual care, and access to MinuteClinic services. Mental-health resources such as counseling support are emphasized, and coverage is often considered solid for full-time colleagues.
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Retirement Support — A dollar-for-dollar 401(k) match up to 5% after one year and an Employee Stock Purchase Plan are consistently highlighted in Total Rewards materials. Feedback suggests retirement programs are a meaningful strength within the overall package.
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Wellbeing & Lifestyle Benefits — Wellbeing offerings include up to 20 no-cost counseling sessions per issue, backup care, tuition assistance, and substantial in-store discounts, alongside broader wellness tools. These everyday perks expand value beyond base pay and can be especially meaningful for full-time schedules.
CVS Health Insights
What We Do
CVS Health is the leading health solutions company that delivers care in ways no one else can. We reach people in more ways and improve the health of communities across America through our local presence, digital channels and our nearly 300,000 dedicated colleagues – including more than 40,000 physicians, pharmacists, nurses and nurse practitioners. Wherever and whenever people need us, we help them with their health – whether that’s managing chronic diseases, staying compliant with their medications, or accessing affordable health and wellness services in the most convenient ways. We help people navigate the health care system – and their personal health care – by improving access, lowering costs and being a trusted partner for every meaningful moment of health. And we do it all with heart, each and every day.
