Quality Review and Audit Senior Analyst – RADV

📋 Description

• • The Quality Review and Audit Senior Analyst – RADV role at The Cigna Group is critical to ensuring compliance, accuracy, and integrity in the Individual and Family Plans (IFP) Risk Adjustment (RA) programs, particularly the Risk Adjustment Data Validation (RADV) audit process. This position directly supports federal regulatory compliance with CMS guidelines, safeguarding the organization against financial and operational risks associated with inaccurate diagnosis coding and audit failures.
• • The person will serve as a key liaison between internal teams, external auditors, and matrix partners to coordinate end-to-end RADV audit activities, including file reconciliation, appeals management, and supplemental diagnosis program support, while driving continuous quality improvement across RA operations.
• • Oversee and coordinate daily operations for IFP RADV audits, ensuring timely execution of audit workflows, file tracking, and issue resolution in alignment with CMS protocols and internal SLAs.
• • Support the Supplemental Diagnosis program by validating diagnosis abstraction, ensuring completeness and accuracy of submitted data, and coordinating with coding teams to address gaps identified during review.
• • Demonstrate expert proficiency in ICD-10-CM coding, CMS guidelines, Official Coding Guidelines, Coding Clinic, and HCC risk adjustment models to accurately assess medical record documentation for compliance and risk score integrity.
• • Apply in-depth knowledge of RADV protocols, EDGE Server Business Rules (where applicable), and HHS Risk Adjustment program requirements to interpret audit findings, manage discrepancies, and ensure adherence to federal standards.
• • Collaborate with Quality Management and external auditors (including Initial Validation Audit Entities) to facilitate smooth audit execution, respond to inquiries, and manage the appeals process with timely, well-documented responses.
• • Identify, document, and communicate operational risks, process gaps, or compliance concerns to leadership and stakeholders in a timely manner, recommending corrective actions to improve audit readiness and program performance.
• • Develop and implement internal processes, workflows, and quality improvement initiatives to enhance consistency, efficiency, and accuracy in RA program execution.
• • Prioritize and manage multiple projects and deadlines in coordination with Quality Mgmt, ensuring alignment with organizational goals and regulatory timelines.
• • Stay current on evolving federal regulations, CMS updates, and HHS guidance related to diagnosis coding, risk adjustment, and audit protocols through continuous learning and professional development.
• • Communicate complex coding and audit concepts clearly and professionally to peers, supervisors, matrix partners, and external stakeholders via verbal, written, and telephonic channels.
• • Contribute to the development and updating of Cigna IFP Coding Guidelines and policy determinations, ensuring organizational practices reflect current industry standards and regulatory expectations.
• • Participate in medical documentation coding reviews as needed to validate diagnosis abstraction accuracy and support education and training initiatives.
• • Mentor and educate team members on RADV processes, coding best practices, and compliance requirements to foster a culture of continuous quality improvement and knowledge sharing.
• • Maintain strict adherence to HIPAA regulations and safeguard Protected Health Information (PHI) in all electronic and physical environments during data handling, review, and reporting.
• • Demonstrate proficiency in Microsoft Office Suite (Outlook, Excel, Word) and Adobe Acrobat for data tracking, reporting, documentation, and workflow management.
• • Work independently with strong self-direction, organizational skills, and attention to detail to meet deadlines, manage competing priorities, and deliver high-quality output consistently.
• • Exhibit flexibility and willingness to assume additional duties as assigned, supporting team objectives and organizational needs beyond core responsibilities.
• • The Quality Review and Audit team operates within Cigna Healthcare’s Risk Adjustment organization, a mission-driven unit dedicated to ensuring accurate risk score calculation and regulatory compliance for Individual and Family Plans. This team plays a pivotal role in preparing for and responding to federal RADV audits, which have significant financial and reputational implications for the organization.
• • Cigna Healthcare is a division of The Cigna Group, a leading health services company committed to improving health, well-being, and peace of mind for those we serve. With a focus on innovation, integrity, and customer-centric solutions, Cigna empowers individuals to achieve better health outcomes through personalized care, preventive services, and data-driven insights.
• • The team fosters a collaborative, inclusive, and learning-oriented environment where expertise is valued, continuous improvement is encouraged, and employees are supported in pursuing professional certifications and career growth.
• • In this role, the individual will deepen their expertise in federal risk adjustment programs, CMS audit procedures, and complex diagnosis coding standards, positioning themselves as a subject matter expert in RADV and RA operations.
• • The position offers significant opportunities to develop leadership, project coordination, and stakeholder management skills through cross-functional collaboration with Quality Mgmt, coding teams, external auditors, and matrix partners.
• • Success in this role can lead to advancement into senior audit, compliance, or risk adjustment management positions within The Cigna Group, particularly for those who demonstrate initiative, analytical thinking, and a commitment to excellence in healthcare compliance.