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Aetna Coding Quality Auditor in Cranberry, Pennsylvania

Req ID: 66217BR

Job Description

Responsible for performing audits of medical records to ensure the 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 written clinical documentation in accordance with all state and federal regulations and internal policies and procedures.

Fundamental Components included but are not limited to:

Performs audits of medical records to ensure all assigned 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-10 codes as appropriate. Effectively communicates the audit process and results to the appropriate departments and management. Assists senior level staff in providing recommendations for process improvement so that productivity and quality goals can be met or exceeded and operational efficiency and financial accuracy can be achieved. Maintains current knowledge of ICD-10 codes, CMS documentation requirements, and state and federal regulations. Performs other related duties as required.

Qualifications Requirements and Preferences:

  • Experience with Microsoft Office products (Word, Excel, Project, PowerPoint, Outlook).

  • Experience with ICD-10 codes required.

  • Experience with Medicare and/or Medicaid Risk Adjustment process required

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

  • Minimum of 3 years recent and related experience in medical record documentation review, diagnosis coding, and/or auditing.

  • Excellent analytical and problem solving skills

  • Effective communications, organizational, and interpersonal skills.

  • High School Diploma or G.E.D.

Technology Experience:

Desktop Tool - Microsoft Outlook, Desktop Tool - TE Microsoft Excel

Additional Job Information:

Candidate will have experience with Medicare Risk Adjustment and HCC coding. Knowledgeable of ICD-9 and ICD-10 Official Coding Guidelines. Displays ability to function independently and can work cooperatively with other as part of a team. Displays organizational commitment and aligns own behavior with the values, needs and priorities of the company.

Benefit Eligibility

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

Job Function: Quality Management

Aetna is an Equal Opportunity/Affirmative Action employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, or protected Veterans status.