Legal Compliance Advisor- Medicare Part C Risk Adjustment Monitoring and Audit

Responsible for Part C audit activities for the Cigna Compliance Department, with particular emphasis on Coding, Risk Adjustment and Coding Decisions. Collaborates with Cigna Compliance colleagues and business partners to drive process improvements, monitor and audit ICD-10 codes submitted to Cigna by providers, identify codes that may be submitted inappropriately and where identified ensure effective corrective action. S/he forges and maintains positive working relationships with business owners, management, regulators and compliance colleagues and demonstrates the ability to influence business partner and/or staff behavior at whatever level and to whatever extent is needed.To be successful, this candidate must exhibit superior analytical, coding skills (including ICD-9 and ICD-10), strong knowledge of HCC’s and risk scores, communication and collaborative skills, as well as the ability to excel in a dynamic, fast-paced environment. The candidate must demonstrate solid command of risk adjustment. This compliance team member must be adept at working with a variety of internal and external stakeholders. S/he will promote an enterprise-wide culture of compliance and provide first-rate support within the Compliance Department and across the business units.

Reports to the Part C Legal Compliance Manager;Monitors transactions and business processes associated with reconciling ICD-9/ICD-10 codes received from providers with the provider’s medical records as well as establishing the appropriate use of codes received;Provides subject matter expertise in response to day-to-day business issues related to coding and risk adjustment;Manage a specific caseload of risk adjustment projects as assigned, from start to finish, in a timely manner;Monitor transactions related to the risk adjustment process and coding (ICD-9/ICD-10) either onsite, via webinar or by means of a desk review. Monitoring risk adjustment transactions include, amongst others, validating universes, preparing and/or executing programs to monitor and monitoring targeted transactions by way of walk-throughs, conducting interviews, and performing tests/reviews;Stay abreast of industry changes and/or trends including but not limited to Federal Risk Adjustment cases;Researches guidelines to ensure Cigna coding best practices remain consistent with CMS RADV Coding Guidance and ICD-10 coding guidelines; Collaborates with all areas of compliance, the special investigations unit, and business owners to drive process improvements and ensure that corrective action plans are tailored and appropriate for the deficiencies identified; andProvide meaningful and appropriate reporting to support compliance audit.

Qualifications:Bachelor’s degree or equivalent.5+ years of experience with Medicare Risk Adjustment-is required.5+ years of experience working with Medicare Advantage, Medicare-Medicaid. Plan (Dual-Eligible) and/or Medicaid.Certified Coding Specialist required.5+ years of experience with auditing.Experience with Risk Adjustment Data Validation Audits required.Strong knowledge of Medicare Risk Adjustment regulations required.Strong knowledge of Risk Adjustment and Hierarchical Condition CategoryPayment model (i.e., v12 and v22) required.This is Hybrid role and requires someone to be in office 3 days a week.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.About The Cigna GroupDoing something meaningful starts with a simple decision, a commitment to changing lives. At The Cigna Group, we’re dedicated to improving the health and vitality of those we serve. Through our divisions Cigna Healthcare and Evernorth Health Services, we are committed to enhancing the lives of our clients, customers and patients. Join us in driving growth and improving lives.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.If you require reasonable accommodation in completing the online application process, please email: SeeYourself@cigna.com for support. Do not email SeeYourself@cigna.com for an update on your application or to provide your resume as you will not receive a response.Qualified applicants with criminal histories will be considered for employment in a mannerconsistent with all federal, state and local ordinances.The Cigna Group has a tobacco-free policy and reserves the right not to hire tobacco/nicotine users in states where that is legally permissible. Candidates in such states who use tobacco/nicotine will not be considered for employment unless they enter a qualifying smoking cessation program prior to the start of their employment. These states include: Alabama, Alaska, Arizona, Arkansas, Delaware, Florida, Georgia, Hawaii, Idaho, Iowa, Kansas, Maryland, Massachusetts, Michigan, Nebraska, Ohio, Pennsylvania, Texas, Utah, Vermont, and Washington State.