Aetna Sr Coding Quality Auditor in Pittsburgh, Pennsylvania

Req ID: 43321BR


Responsible for performing audits of medical records to ensure the ICD-9/ICD-10 codes that are submitted to the Centers for Medicare and Medicaid Services (CMS) for the Risk Adjustment Payment System (RAPS) are appropriate, accurate, and supported by clinical documentation in accordance with all State and Federal regulations and internal policies and procedures.

Monitors quality amongst all coding staff. Assists manager with daily operations, as needed

Fundamental Components:

Performs audits of medical records to ensure all assigned ICD-9/ICD-10 codes are accurate and supported by written clinical documentation.

Provides education to internal staff and external providers based on audit findings; provides general education on ICD-9/ICD-10 codes as appropriate.

Serves as the training resource and subject matter expert to other team members for questions regarding ICD-9/ICD-10 coding and documentation requirements.

Effectively communicates the audit process and results to the appropriate departments and management.

Interfaces with providers and Health Plans to resolve disputes regarding appropriate coding and documentation requirements.

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 financial accuracy is achieved.

Remains current on ICD-9/ICD-10 codes, CMS documentation requirements, and State and Federal regulations.

Performs other related duties as required.


Minimum of 4 years recent experience in medical record documentation review, diagnosis coding, and/or auditing.

CPC (Certified Professional Coder) or CCS-P (Certified Coding Specialist-Physician) required

Experience with ICD-10 codes required.

Experience with Medicare and/or Medicaid Risk Adjustment process required

Experience with Microsoft Office products (Word, Excel, Project)


The highest level of education desired for candidates in this position is a Bachelor's degree or equivalent experience.

Telework Specifications:

This position is full time work from home.


Displays ability to function independently and in a collaborative work environment. Work cooperatively with others as part of a team. Displays organizational commitment: aligns own behavior with the values, needs and priorities of Aetna.

Aetna is about more than just doing a job. This is our opportunity to re-shape healthcare for America and across the globe. We are developing solutions to improve the quality and affordability of healthcare. What we do will benefit generations to come.

We care about each other, our customers and our communities. We are inspired to make a difference, and we are committed to integrity and excellence.

Together we will empower people to live healthier lives.

Aetna is an equal opportunity & affirmative action employer. All qualified applicants will receive consideration for employment regardless of personal characteristics or status. We take affirmative action to recruit, select and develop women, people of color, veterans and individuals with disabilities.

We are a company built on excellence. We have a culture that values growth, achievement and diversity and a workplace where your voice can be heard.

Benefit eligibility may vary by position. Click here to review the benefits associated with this position.

Aetna takes our candidate's data privacy seriously. At no time will any Aetna recruiter or employee request any financial or personal information (Social Security Number, Credit card information for direct deposit, etc.) from you via e-mail. Any requests for information will be discussed prior and will be conducted through a secure website provided by the recruiter. Should you be asked for such information, please notify us immediately.

Job Function: Quality Management