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 conducting complex audits, reviews and assessments of medical records coded by internal teams prior to the submission to the Centers of 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. Contributes to compliance reporting and documentation, highlighting findings, recommendations, and areas of concern to be delivered to coding resources.
- Adhere to stringent timelines consistent with project deadlines and directives.
- Demonstrates a strong commitment to enhancing and promoting quality; consistently delivers accurate and thorough work, and supports others in achieving the same standards through effective mentoring and instruction.
- Serves as the training resource and subject matter expert to vendors, providers and other team members for questions regarding ICD coding and documentation requirements.
- Comprehensive knowledge of coding guidelines and regulations to meet compliance requirements, such as establishing medical necessity.
- 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.
- Evidenced knowledge of problem solving and decision making skills
Required Qualifications
- 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.
Completion of AAPC/AHIMA training program for core credential (CPC, CCS-P) with associated work history/on the job experience equal to approximately 5 years for CPC.
CPC (Certified Professional Coder) or CCS-P (Certified Coding Specialist-Physician) and CRC (Certified Risk Adjustment Coder) required.
CPMA (Certified Professional Medical Auditor) or CDEO (Certified Documentation Expert Outpatient) preferred.
Preferred 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.
- Experience with Medicare and/or Commercial and/or Medicaid Risk Adjustment process and Hierarchical Condition Categories (HCC) required.
- Expertise in medical documentation, fraud, abuse and penalties for documentation and coding violations based on governmental guidelines.
Education
- Bachelor's degree preferred specialized training/relevant professional qualification, or equivalent work experience.
Anticipated Weekly Hours
40Time Type
Full timePay Range
The typical pay range for this role is:
$46,988.00 - $112,200.00This 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
- 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).
- Completion of AAPC/AHIMA training program for core credential (CPC, CCS-P) with associated work history (~5 years for CPC).
- CPC (Certified Professional Coder) or CCS-P (Certified Coding Specialist-Physician) and CRC (Certified Risk Adjustment Coder).
- Expertise in medical documentation, fraud, abuse and penalties for documentation and coding violations based on governmental guidelines.
- Comprehensive knowledge of coding guidelines and regulations to meet compliance requirements, such as establishing medical necessity.
- CPMA (Certified Professional Medical Auditor) or CDEO (Certified Documentation Expert Outpatient).
- Experience with International Classification of Disease (ICD) codes.
- Computer proficiency including Microsoft Office products (Word, Excel, Access, PowerPoint, Outlook) and industry standard coding applications.
- Bachelor's degree preferred or equivalent work experience/specialized training.
- Demonstrated problem solving and decision-making skills and ability to meet stringent timelines.
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.
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