Individual & Family Plans (IFP) Quality Review and Audit Manager - Remote - Cigna Healthcare

The Quality Review and Audit Manager (“Manager”) is responsible for the day-to-day management and performance of a team of coding auditors, ensuring delivery of accurate data and meeting of strategic objectives within the Individual and Family Plan’s (IFP) Risk Adjustment Operations.   The Manager will ensure compliance, quality standards, and coding guidelines are followed, while supporting optimal performance on the team, ensuring external coding partners are meeting accuracy standards and applying coding rules and best practices in a compliant manner, developing and delivering any specific coding education to address gaps or deficiencies, and participating in Risk Adjustment activities and projects within the team, as identified by leadership.

Core Responsibilities:

• Develops, supports & executes coding strategies, setting priorities & making recommendations for continuous process & procedure improvement efforts
• Owns, develops & implements coding projects that support data submissions to government oversight agencies, and internal & RADV audits
• Leads a team of ~8 coding auditors ensuring adherence to federal and state regulations, development of compliant coding guidelines, and accurate coding guideline interpretation & application while meeting the highest quality accuracy standards
• Ensures team has necessary tools, resources & support to execute on defined strategy and deliver results
• Leads multiple cross-functional coding initiatives for risk adjustment performance & enhancements
• Works independently to identify issues and trends to facilitate continuous quality improvement; liaising with matrix teams and external coding partners to improve data and outcomes
• Cultivates effective business partnerships to ensure issues are managed proactively and communicated clearly, accurately and effectively with all business partners including external coding partners.
• Coaches, trains and holds team accountable for adherence to coding guidelines, HHS risk adjustment rules & regulations and applicable individual State requirements
• Determines, monitors, manages coding performance metrics & ensuring 95% accuracy of higher along with compliant performance results from external coding partners
• Works closely with internal stakeholders and matrix partners to set and achieve ongoing performance metrics
• Manages key performance indicators & works directly with leadership to report, improve trends, challenges, performance, optimization of technologies, programs, processes, people
• Expert in improving performance, managing change, and problem solving
• Leverages internal resources and independent judgment and discretion to resolve complex coding and data challenges, communicating with team and external coding partners to achieve successful outcomes
• Participates in regularly scheduled feedback and information exchange sessions with key business partners
• Serves as a Subject Matter Expert for project and business development teams
• Leads new platform implementations, developing and maintaining relationships with key external coding partner SMEs to ensure quality output in support of Risk Adjustment and RADV processes
• Transforms complex coding concepts into actionable guidance & outcomes
• Drives removal of roadblocks, project status communication, insights, with resulting business recommendations to leadership

Qualifications:

• Bachelor’s degree or higher, preferred; High School diploma required
• 5+ years minimum coding experience required, with certification by either the American Health Information Management Association (AHIMA) or the American Academy of Professional Coders (AAPC) in one of the following certifications:
• Certified Professional Coder (CPC)
• Certified Coding Specialist for Providers (CCS-P)
• Certified Coding Specialist for Hospitals (CCS-H)
• Registered Health Information Technician (RHIT)
• Registered Health Information Administrator (RHIA)
• Payer experience preferred
• Certified Risk Adjustment Coder (CRC) certification preferred
• Supervisory or management experience required with the ability to effectively manage a team and drive results
• Knowledge of CMS RADV audits, 2 years + of RADV coding experience is preferred
• Familiarity with HHS (PPACA) Risk Adjustment is highly preferred
• Proficiency with CMS/HHS regulations and polices related to documentation and coding, both with Inpatient and Outpatient documentation
• HCC coding experience and Risk Adjustment knowledge strongly preferred
• Strong interpersonal, presentation, and communication skills required, written and verbal
• Strong analytical, organizational skills, and detail-oriented with the ability to review and analyze coding data and identify areas of improvement
• Problem-solving skills with the ability to identify coding issues and develop solutions to ensure compliance and accuracy
• Ability to provide clear guidance through change processes and in ambiguity, identifying actionable items and executing on plan
• Ability to work independently, with strong collaboration and relationship management skills
• Proficiency in Microsoft Office skills related to Excel, PowerPoint MS Word, and Adobe Acrobat

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 89,000 - 148,300 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.