Revenue Integrity Consultant

Job Description
CVS now a Fortune 4 company!

Job Group Summary
Management professionals develop and implement strategies and policies to direct our operations, subsidiaries, major projects, and functional groups. They help our business units - and our company - meet corporate objectives and compete more successfully in the marketplace.

Family Summary/Mission
Develop, implement, support, and promote Health Services strategies, tactics, policies, and programs that drive the delivery of quality healthcare to establish competitive business advantage for Aetna. Health Services strategies, policies, and programs are comprised of utilization management, quality management, network management and clinical coverage and policies.

Position Summary/Mission
Involved in initiative planning, ongoing client relationship management and satisfaction for assigned initiatives that impact the delivery of products and services to the internal and external environment (See Family Summary). Collaborates with external vendors, external consultants, consulting team members and/or matrixed staff as required in support of initiatives. Accountable for transferring knowledge, best practices (external and internal), methodology and tools to client organizations. Participates as a team member, may be responsible for concurrent initiatives or act as team lead for less complex projects based on resource requirements.

Fundamental Components & Physical Requirements include but are not limited to (* denotes essential functions)

Identifies and recommends opportunities for process improvements at the practice level to ensure member Risk Adjustment accuracy and quality care gap closure.
Supports Market Director of STARS and Risk Adjustment while serving as a liaison to various integrated lines of business, Corp. Revenue Integrity, and market health risk educator to provide in-depth knowledge and expertise to support the education of providers to capture member risk accurately*.
Participates and supports metric integration and execution for optimal results related to Risk Adjustment and associated areas, including quality measures. *
Shares joint accountability for initiative's return on investment *
Responsible for educating providers on how to properly document medical services and interventions received during member encounters, including proper coding and claim submission for services rendered. *
Supports holistic solutions and/or key strategic plans.
Proactively identifies opportunities for improvement within assigned initiatives
Conducts thorough business case and external customer value analysis to determine selection, prioritization positioning and approach for broadest range of potential solutions (e.g., outsourcing, process improvements, technology solutions)
Participates in influencing client contracting process, builds optimal client relationship for results and deliverables and manages relationship throughout engagement *
Communicates compelling and concise results to empower client groups in decision making process regarding project opportunities*
Participates in initiative planning as required. Supports engagement using a disciplined repeatable methodology*
Designs, develops interventions, and facilitates work sessions. *
Develops and delivers all required analysis, reporting and presentation materials.
Gathers, analyzes, and synthesizes business intelligence to drive achievement of strategic business objectives*
Builds and utilizes diverse internal and external networks, as appropriate, for data gathering and best practice identification.
Identifies barriers utilizing critical thinking skills to identify improvement opportunities, communicate them to the market team, and help facilitate gains in efficiency and appropriate risk score capture.
Leads work groups to develop learning strategies to improve health care delivery performance. *
Serves as the training resource and subject matter expert to regionally aligned network practices.
Shares best practices in Risk Adjustment across all sites/regions. *
Simultaneously manages multiple, complex projects.

Required Qualifications
Education and Certification Requirements
Bachelor's degree or equivalent recent and related work experience.
CPC (Certified Professional Coder) certification or CRC (Certified Risk Adjustment Coder) certification required.

COVID Requirements
COVID-19 Vaccination Requirement
CVS Health requires its Colleagues in certain positions to be fully vaccinated against COVID-19 (including any booster shots if required), where allowable under the law, unless they are approved for a reasonable accommodation based on disability, medical condition, pregnancy, or religious belief that prevents them from being vaccinated.
  • If you are vaccinated, you are required to have received at least one COVID-19 shot prior to your first day of employment and to provide proof of your vaccination status within the first 30 days of your employment. For the two COVID-19 shot regimen, you will be required to provide proof of your second COVID-19 shot within the first 60 days of your employment. Failure to provide timely proof of your COVID-19 vaccination status will result in the termination of your employment with CVS Health.
  • If you are unable to be fully vaccinated due to disability, medical condition, pregnancy, or religious belief, you will be required to apply for a reasonable accommodation within the first 30 days of your employment in order to remain employed with CVS Health. As a part of this process, you will be required to provide information or documentation about the reason you cannot be vaccinated. If your request for an accommodation is not approved, then your employment may be terminated.

Preferred Qualifications
Background/Experience Desired
5+ years' experience with one or more of the following methodologies: management consulting, project consulting, business process consulting, financial strategic analysis, strategic business planning, and/or risk coding management consulting.
Minimum of 3 years recent and related experience in medical record documentation review, diagnosis coding, and/or auditing.
Experience with ICD-10 codes required.
Experience with Medicare and/or Commercial risk adjustment process required.
Experience/understanding of electronic medical records/electronic health records in the office setting required.
Knowledge of regulatory/accreditor guidelines and NCQA guidelines
Knowledge of quality STARS measures
Demonstrated experience successfully implementing change in complex organizations.
Operational experience in a relevant discipline

Education and Certification Requirements
Bachelor's degree or equivalent recent and related work experience.
CPC (Certified Professional Coder) certification or CRC (Certified Risk Adjustment Coder) certification required.

Additional Information (situational competencies, skills, work location requirements, etc.)
Position will eventually require occasional regional travel to Aetna's provider offices, clinics, and facilities.
Position requires proficiency with computer skills which includes navigating multiple systems, Microsoft Office, and keyboarding.
Effective communication skills required, both verbal and written.
Ability to multi-task, prioritize and effectively adapt to a fast-paced changing environment
Position is sedentary work involving periods of sitting, talking, listening. Work requires sitting for extended periods, talking on the telephone, and typing on the computer.
Work requires the ability to perform close inspection of handwritten and computer-generated documents as well as a PC monitor.
Excellent skills in the following areas: team leadership & building, analytical, planning, influencing, relationship creation and organizational management. Also, time management and critical thinking skills.

Business Overview
At Aetna, a CVS Health company, we are joined in a common purpose: helping people on their path to better health. We are working to transform health care through innovations that make quality care more accessible, easier to use, less expensive and patient-focused. Working together and organizing around the individual, we are pioneering a new approach to total health that puts people at the heart.

We are committed to maintaining a diverse and inclusive workplace. CVS Health is an equal opportunity and affirmative action employer. We do not discriminate in recruiting, hiring or promotion based on race, ethnicity, gender, gender identity, age, disability or protected veteran status. We proudly support and encourage people with military experience (active, veterans, reservists and National Guard) as well as military spouses to apply for CVS Health job opportunities.