Description:
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:
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.

Background Experience:
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 requiredCPC (Certified Professional Coder) or CCS-P (Certified Coding Specialist-Physician) requiredExcellent analytical and problem solving skillsEffective communications, organizational, and interpersonal skills. High School Diploma or G.E.D.

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

Potential Telework Position:
Yes

Percent of Travel Required:
0 - 10%

EEO Statement:
Aetna is an Equal Opportunity, Affirmative Action Employer

Benefit Eligibility:
Benefit eligibility may vary by position. Click here to review the benefits associated with this position.

Candidate Privacy Information:
Aetna takes our candidate's data privacy seriously. At no time will any Aetna recruiter or employee request any financial or personal information (Social Security Number, Credit card information for direct deposit, etc.) from you via e-mail. Any requests for information will be discussed prior and will be conducted through a secure website provided by the recruiter. Should you be asked for such information, please notify us immediately.

Click To Review Our Benefits (PDF)