Coding Data Quality Auditor

We’re building a world of health around every individual — shaping a more connected, convenient and compassionate health experience. At CVS Health®, you’ll be surrounded by passionate colleagues who care deeply, innovate with purpose, hold ourselves accountable and prioritize safety and quality in everything we do. Join us and be part of something bigger – helping to simplify health care one person, one family and one community at a time. Position Summary Responsible for performing audit and abstraction of medical records (provider and/or vendor) to identify and submit ICD 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. Responsibilities Proven ability to support coding judgment and decisions using industry standard evidence and tools. Proficient in abstraction and assignment of accurate medical codes for diagnoses as documented by physicians and other qualified healthcare providers in the office and/or facility setting. Sound knowledge of coding guidelines and regulations to meet compliance requirements, such as establishing medical necessity. Identify clinically active vs. historical conditions. Diagnosis codes must be appropriate, accurate, and supported by clinical documentation in accordance with all State and Federal regulations and internal policies and procedures. Utilize medical records to ensure support is documented for etiology and manifestations of disease processes. Adhere to stringent timelines consistent with project deadlines and directives. Conducts self-process audits to ensure compliance with internal policies and procedures as well as regulatory guidance from CMS, OIG or other Regulatory body. 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. In depth knowledge of medical terminology and anatomy for all body systems. Understand the audit process for risk adjustment models. Performs other related duties as required. Required Qualifications CPC (Certified Professional Coder) or CCS-P (Certified Coding Specialist-Physician). Computer proficiency including experience with Microsoft Office products (Word, Excel, Access, PowerPoint, Outlook, industry standard coding applications). Capable of making outbound phone calls and faxes to providers for record retrieval and provider communications regarding audits. Experience with International Classification of Disease (ICD) codes required. Minimum of 1 year recent and related experience in medical record documentation review, diagnosis coding, and/or auditing. Preferred Qualifications 3 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) and 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 AA/AS 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 1-2 years for CPC. CPC (Certified Professional Coder) or CCS-P (Certified Coding Specialist-Physician) required. Anticipated Weekly Hours 40 Time Type Full time Pay Range The typical pay range for this role is: $18.50 - $38.82. 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: 07/07/2026 Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state and local laws. #J-18808-Ljbffr 4062 Aetna Resources, LLC