The job profile for this position is Provider Data Senior Analyst, which is a Band 3 Senior Contributor Career Track Role.

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Job Summary:

This role is responsible for supporting Cigna Medicare Advantage’s Risk Adjustment & Stars program for assigned populations in an operational market. The role will be accountable for assigned provider groups reaching risk adjustment and stars related annual metrics. This role will work directly with providers to assist in achieving accurate and complete coding documentation and addressing Stars gaps in care. The role will work under the direction of Risk Adjustment & Stars Provider Education Supervisor and/or Manager to reach overall operational market goals in conjunction with market network operations, stars strategy and vendor partners. The role will provide subject matter expertise to assigned providers and internal matrix partners of Cigna Medicare’s programs specific to CMS Risk Adjustment and HCC Coding Processes. It will require expertise in ICD-10-CM/outpatient and CPT coding principles and guidelines and use of own discretion to deliver compliant, effective strategies to meet established goals.

Core Responsibilities:

• Responsible for identifying and influencing adoption of resources and processes to reach risk adjustment and quality goals of assigned provider groups (PODs/IPAs).
• Accountable to complete and accurate review of multi-year diagnosis coding of assigned population.
• Understands, develops, tracks, monitors and reports on key program performance metrics for coding initiatives.
• Work closely with matrix partners including Network Operations, Stars or Clinical Operations, and vendors to ensure provider office communications are effective and efficient.
• Review and act on any assigned audit educational opportunities timely and provide primary care or specialty care provider trainings as necessary to educate on audit findings.
• Analyze data regarding trends or patterns identified in provider office diagnosis coding. Implement provider office education, where necessary, and provide formal training to providers and staff regarding coding and documentation standards.
• Rely upon independent judgment and decision-making at provider sites, whether conducting chart review or providing training/education, both for historical and/or real time data.
• Develop relationships with clinical providers/staff and communicate coding and documentation guidelines.
• Conduct provider training on health plan coding initiatives guidelines and requirements of the Risk Adjustment program to ensure correct coding and documentation.
• Conduct chart reviews for providers and review provider performance. This is accomplished by doing virtual training sessions, traveling to the individual practices and/or performing side-by-side education.
• Assists with research, analysis and response to inquiries from all internal and external audit departments regarding compliance, coding, and inappropriate coding.
• Attend risk adjustment and quality provider meetings for assigned provider groups to provide updates, recommendations, or education (may occur be before/after normal business hours)
• Perform the minimum number of coding quality reviews consistent with established departmental goals.
• Maintain strictest confidentiality based on HIPAA privacy policy.
• Maintain current knowledge of coding guidelines and relevant federal regulations through the use of current ICD-10 CM, CPT, HCPCS
• Assure compliance by delivering quality services and meeting all contractual, state & federal legal and regulatory requirements.
• Maintain CEU credits to ensure credentials are kept up to date.

MinimRequirements:

• Coding certification required through AHIMA or AAPC (at least one of the below):
  • Certified Professional Coder (CPC)
  • Certified Risk Adjustment Coder (CRC)
  • Certified Coding Specialist for Providers (CCS-P)
  • Registered Health Information Management Technician (RHIT)
• At least two (2) years’ of hospital inpatient / outpatient or medical office coding experience, preferably two (2) years risk adjustment coding experience.
• Excellent written and verbal communication skills.
• Prior experiences teaching/training others on correct coding guidelines and have the ability to present to large groups of Physicians/Providers.
• Extensive knowledge and adherence to ICD-10-CM/outpatient and CPT coding principles and guidelines.
• Excellent understanding of medical terminology, disease process and anatomy and physiology. 
• Working knowledge of CPT/Evaluation and Management guidelines.
• Working Knowledge of CMS Risk Adjustment and HCC Coding Process.
• Strong computer skills (i.e. MS Word, Excel, PowerPoint).
• Ability to drive within assigned areas or overnight travel for internal or external meetings
• Capacity to attend provider meetings day/evening/weekends as needed within assigned areas. These meetings may be virtual or in person as defined by manager/leadership.

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.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.

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