risk adjustment Clinical reviewerAmeridea

RISK ADJUSTMENT CLINICAL REVIEWER
 
KEY DUTIES AND RESPONSIBILITIES:
Review medical records to determine the appropriate medical information or clinical indicators and identify suspect conditions.
Implements clinical data review strategy to meet the needs of protocol and ensure alignment with program-level standards.
Ensures there is consistency/accuracy in data review within the assigned protocol; supports and contributes to the development and embedding of new protocols
Communicates with providers, coders, executives, and other staff the clinical requirements, documentation guidelines, and coding standards for the suspect diagnosis capture.
Enter suspect diagnosis and sources of clinical indicators and other clinical data into a database or tool by following data entry standards.
Maintain a comprehensive tracking and management tool for assigned medical record reviews.
Meet and maintain production and accuracy metrics, as defined
Report finding resulting from chart review
When necessary, assist with training on appropriate coding of medical charts and documentation as required
Follow HIPAA compliance protocol
Other projects and duties as assigned
EDUCATION AND EXPERIENCE:
RN and a minimum of 2 years of progressive clinical experience
At least two (2) years of experience in chart review for clinical indications of medical conditions and diagnosis and management options with emphasis on the managed care industry
Experience in working with various electronic medical records
ESSENTIAL SKILLS AND ABILITIES:
Familiarity and understanding of CMS HCC models, Risk Adjustment coding, and data validation requirements (preferred)
Strong computer skills and Computer proficiency including Excel, Word, Microsoft, and other programs and applications with access to high-speed internet service
Ability to medically review
Ability to function under pressure and deadline-oriented project demands manage multiple initiatives
Must be a licensed Registered Nurse (RN)
Demonstrated success in using oral and written communication skills to convey information and influence, inform, provide training, and/or guide others
Experience working in a team environment within a matrix organization
Ability to code using an ICD-10-CM code book (without using an encoder)
Knowledge of HIPAA, recognizing a commitment to privacy, security, and confidentiality of all medical chart documentation
Strong clinical knowledge related to chronic illness diagnosis, treatment, and management
High-speed Internet access
Extensive knowledge of ICD-10-CM outpatient diagnosis coding guidelines (knowledge and demonstrated understanding of Risk Adjustment coding and data validation requirements is highly preferred)
Reliability and a commitment to meeting tight deadlines (24-to-48-hour turnaround time on most charts)
Personal discipline to work remotely without direct supervision
Analytical skills
Self-starter that can work independently and collaboratively, prioritize tasks, and has initiative and excitement to take on unfamiliar tasks.
Advanced knowledge of word processing, graphic presentation, and computer software related to specific tasks
Demonstrated excellent computer and word processing skills with special emphasis on calendaring, presentation, and spreadsheet capabilities
Working knowledge of company policies, procedures, and operations
Excellent composition, grammar, and business language skills
Excellent communication and interpersonal skills with the ability to effectively communicate with all levels of management, patients, and family members.
Creative, flexible, well-organized, resourceful, and detail-oriented
Excellent judgment in handling confidential and sensitive information
Ability to work independently, set priorities and handle multiple tasks with a high level of efficiency
Establishing and maintaining cooperative working relationships with others
Ability to work across locations and time zones
CORE COMPETENCIES:
Instills trust
Customer focus
Manages ambiguity
Collaborates
Drives results