The Quality Review and Audit Manager ("Manager") is responsible for the day-to-day management and performance of a team of certified Risk Adjustment coding auditors, ensuring delivery of accurate data, and meeting of strategic objectives within the Individual and Family Plan's (IFP) Risk Adjustment Operations. The Manager will ensure compliance, quality standards, and coding guidelines are followed, while supporting optimal performance on the team, contributing to team and business objectives.

Core Responsibilities:

• Leads a team of professionals, providing leadership, inspiration, and connection to the day-to-day activities contributing to broader organizational goals.


• Manages staffing, workflows, reporting, and quality control for medical record outreach and retrieval and medical record processing in accordance with program requirements.


• Drives ongoing improvement in operational efficiencies, staff utilization, and performance monitoring.


• Collaborates with internal partners to identify and generate alternative medical data and documentation retrieval sources, such as digital direct, EMR access, CCDA, or other.


• Manages and oversees multiple cross-functional activities and vendor-solution services focused on medical record administration, quality control, timely receipt, and alternative retrieval opportunities.


• Manages & coordinates efforts with applicable resources to ensure chart quality and completeness, setting a standard of excellence in health information administration, and coordinating efforts with Risk Validation data management & architecture, analytics, & coding teams.


• Monitors key operational performance indicators and works jointly with leadership to identify, adjust and report on influencing factors.


• Evaluates trends on both provider engagement and/or vendor performance for continuous improvement efforts and/or SLA adherence.


• Coordinates supporting vendor solutions to ensure timely & successful execution of program requirements and/or day-to-day operations/solutions perform as designed.


• Ensures ongoing, timely & persistent efforts and/or other alternative means pursued to capture complete & timely receipt of applicable health record information.


• Identifies areas of opportunity and inefficient processes in chart administration activities and develops & executes strategies to minimize administrative burden, improve timeliness, and track performance improvement efforts.


• Supports provider education or audit opportunities as needed based on timely chart retrieval receipts, EMR integration activities and chart compliancy reviews.


• Establishes operational program directives and priorities, collaborating with applicable matrix partners, and manages accordingly to communicate expectations and timing as applicable for successful execution of business objectives.


• Ensures projects are completed within committed time and budget and are integrated with other business and related projects.

Minimum Qualifications:

• Bachelor's degree highly preferred or minimum 5 years equivalent relevant work experience.


• HHS / ACA Risk Adjustment knowledge preferred


• Demonstrated ability to successfully manage multiple, complex, large Enterprise programs/projects.


• Five (5) years of proven experience in managing healthcare document preparation & operations related to medical records, clinical, or audit services.


• Coding certification by either the American Health Information Management Association (AHIMA) or the American Academy of Professional Coders (AAPC) required in one of the following:
  
  
  • Certified Professional Coder (CPC)
  
  
  • Certified Coding Specialist for Providers (CCS-P)
  
  
  • Certified Professional Compliance Officer (CPCO)
  
  
  • Registered Health Information Technician (RHIT)
  
  
  • Registered Health Information Administrator (RHIA)
  
  
  • Certified Risk Adjustment Coder (CRC)
  
  
  
  


• Proficiency in all Microsoft Office applications, i.e. Excel, Word, PowerPoint, and Access.


• Must have familiarity with Federal/State regulations, CMS medical record requirements, RADV protocols.


• Five (5) years of experience in managing call center and/or operations production staff.


• Ability to effectively motivate & engage others, self-starter, ability to manage program under minimal direction.


• Exceptional communication skills, including written and verbal (formal and informal).


• Demonstrated change agent skills within a matrix environment

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.

For this position, we anticipate offering an annual salary of 86,900 - 144,900 USD / yearly, depending on relevant factors, including experience and geographic location.

This role is also anticipated to be eligible to participate in an annual bonus plan.

We want you to be healthy, balanced, and feel secure. That's why you'll enjoy a comprehensive range of benefits, with a focus on supporting your whole health. Starting on day one of your employment, you'll be offered several health-related benefits including medical, vision, dental, and well-being and behavioral health programs. We also offer 401(k) with company match, company paid life insurance, tuition reimbursement, a minimum of 18 days of paid time off per year and paid holidays. For more details on our employee benefits programs, visit Life at Cigna Group .

About Cigna Healthcare

Cigna Healthcare, a division of The Cigna Group, is an advocate for better health through every stage of life. We guide our customers through the health care system, empowering them with the information and insight they need to make the best choices for improving their health and vitality. 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.

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.

Qualified applicants with criminal histories will be considered for employment in a manner consistent with all federal, state and local ordinances.