Quality Review And Audit Analyst

Quality Review and Audit Analyst#26-14657 Franklin, TN Onsite Job Description

Reason:

Peak Period

Department:

IFP RISK ADJUSTMENT

Job Category:

Business Operations

Job Title:

Quality Review and Audit Analyst

Duties:

The Risk Adjustment Quality & Review Analyst in IFP brings medical coding and Hierarchical Condition Category expertise to the role, evaluates complex medical conditions, determines compliance of medical documentation, identifies trends, and suggests improvements in data and processes for Continuous Quality Improvement (CQI).

Key Job Functions:

• Conduct medical records reviews with accurate diagnosis code abstraction in accordance with Offic ial Coding Guidelines and Conventions, Client IFP Coding Guidelines and Best Practices, HHS Protocols and any additional applicable rule set.
• Utilize HHS' Risk Adjustment Model to confirm accuracy of Hierarchical Condition Categories (HCC) identified from abstracted

ICD-10-CM

diagnosis codes for the correct Benefit Year.

• Apply longitudinal thinking to identify all valid and appropriate data elements and opportunities for data capture, through the lens of HHS' Risk Adjustment.
• Perform various documentation and data audits with identification of gaps and/or inaccuracies in risk adjustment data and identification of compliance risks in support of IFP Risk Adjustment (RA) programs, including the Risk Adjustment Data Validation (RADV) audit and the Supplement Diagnosis submission program. Inclusive of Quality Audits for vendor coding partners.
• Collaborate and coordinate with team members and matrix partners to facilitate various aspects of coding and Risk Adjustment education with internal and external partners.
• Coordinate with stake holders to execute efficient and compliant RA programs, raising any identified risks or program gaps to management in a timely manner.
• Communicate effectively across all audiences (verbal & written).
• Develop and implement internal program processes ensuring CMS/HHS compliant programs, including contributing to Client IFP Coding Guideline updates and policy determinations, as needed.

Education & Experience:

The Quality Review & Audit Analyst will have a high school diploma and at least 2 years' experience in one of the following Coding Certifications by either the American Health Information Management Association (AHIMA) or the American Academy of Professional Coders (AAPC): o Certified Professional Coder (CPC) o Certified Coding Specialist for Providers (CCS-P) o Certified Coding Specialist for Hospitals (CCS-H) o Registered Health Information Technician (RHIT) o Registered Health Information Administrator (RHIA) o Certified Risk Adjustment Coder (CRC) certification Minimum Qualifications

• Experience with medical documentation audits and medical chart reviews and proficiency with

ICD-10-CM

coding guidelines and conventions

• Familiarity with CMS regulations for Risk Adjustment programs and policies related to documentation and coding compliance, with both Inpatient and Outpatient documentation
• HCC coding experience preferred
• Computer competency with excel, MS Word, Adobe Acrobat
• Must be detail oriented, self-motivated, and have excellent organization skills
• Understanding of medical claims submissions is preferred
• Ability to meet timeline, productivity, and accuracy standards 3

Non-Negotiable Skills:

• HCC Knowledge or Experience (Basic)
• Certification needs to be active (at least 1)
• Basic knowledge of Microsoft products especially Excel

Skills:

.

Keywords:

Education:

.

Skills and Experience:

Required Skills:

MEDICAL DOCUMENTATION AUDITS

MEDICAL

CHART REVIEWS

ICD-10-CM

CODING GUIDELINES

ICD-10-CM

CODING CONVENTIONS

CMS

REGULATIONS FOR RISK ADJUSTMENT PROGRAMS

INPATIENT

DOCUMENTATION COMPLIANCE

OUTPATIENT

DOCUMENTATION COMPLIANCE

HIERARCHICAL

CONDITION CATEGORIES

(HCC) CODING

Additional Skills:

MEDICAL CLAIMS SUBMISSIONS

MICROSOFT EXCEL MICROSOFT WORD ADOBE ACROBAT DETAIL

ORIENTATION

SELF-MOTIVATION ORGANIZATIONAL SKILLS HCC CODING UNDERSTANDING

OF MEDICAL CLAIMS SUBMISSIONS

Languages:

English Read Write Speak

Minimum Degree Required:

Completed High School (Diploma or GED)

Certifications & Licenses:

AAPC AHIMA Certification (American Health Information Management Association) Certified Coding Specialist for Hospitals Certified Coding Specialist for Providers Certified Professional Coder Certified Risk Adjustment Coder Registered Health Information Administrator Registered Health Information Technician

Patents:

No

Publications:

No

Veteran Status:

No # of

Positions:

3

Schedule:

Start Date:

06/08/2026

Estimated End Date:

09/25/2026

Hours Per Week:

40.00

Hours Per Day:

8.00

Interview Notes:

Monday

• Friday no earlier than 6:30am EST and no later than 9am EST
• work 8 hour shift with 30 minute lunch Training Hours 9am
• 5:30pm EST 100% Remote

Financials:

Currency USD EEO:

"Mindlance is an Equal Opportunity Employer and does not discriminate in employment on the basis of

• Minority/Gender/Disability/Religion/LGBTQI/Age/Veterans.

"