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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
Education BA/BS 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 3 years for CPC.
5-8 years encompassing additional credentials and/or application of credentials.
Anticipated Weekly Hours
40
Time Type
Full time
Pay Range
The typical pay range for this role is:
$21.10 - $44.99
This 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.
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.
Additional details about available benefits are provided during the application process and on Benefits Moments.
We anticipate the application window for this opening will close on: 10/10/2026
Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state and local laws.
