Aetna Senior Coding Quality Auditor in Baltimore, Maryland
Req ID: 62375BR
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 clinical documentation in accordance with all State and Federal regulations and internal policies and procedures.
Leads dispute resolutions.
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.
Serves as the training resource and subject matter expert to other team members for questions regarding 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-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.
Minimum of 4 years recent and related experience in medical record documentation review, diagnosis coding, and/or auditing.
Experience with Medicare and/or Medicaid Risk Adjustment process required.
CPC (Certified Professional Coder) or CCS-P (Certified Coding Specialist-Physician) required.
Excellent analytical and problem solving skills.
Effective communications, organizational, and interpersonal skills.
High School Diploma or G.E.D.
Information Technology - Certified Professional Coder (CPC)
Desktop Tool - TE Microsoft Excel
Additional Job Information:
- For the Finance organization, if you hold the CPC (Certified Professional Coder) certification, you will be required to obtain the CRC (Certified Risk Adjustment Coder) certification within 6 months post hire
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.