The Clinical Review Specialist will be responsible reviewing medical records to abstract ICD-10 codes that map to HCCs from a variety of different CMS Hierarchy models including Medicare Advantage, PACE, Commercial, and Medicaid CDPS model. In addition to abstracting diagnosis codes, the Clinical Review Specialist also audits medical records and validates entries that have been submitted to CMS.

Responsibilities

• Conducts onsite and remote audits of medical records (paper, EMR, hybrid)
• Adheres to compliance of Medicare, Medicaid, and Commercial risk adjustment guidelines with precision.
• Understands, respects, and applies client specific guidelines
• Adheres to audit and medical record review schedules to meet client expectations and government-regulated deadlines
• Shares trends (positive and constructive) with Coding Manager and Team Leads for client consultation/collaboration
• Regularly participates in peer review; provide and receive feedback
• Ensures accurate documentation to support all audits
• Assures adherence to and currency with internal and external regulatory guidelines:
  • CMS/HHS
  • DOH
  • HIPAA, HITECH, and Fraud Waste & Abuse
  • Medical coding protocols
• Provides clinical intellect and expertise to system analytics via project assignments as well as on an ad hoc basis
• Participates on client and prospect conference calls, presentations, and in-person meetings as needed
• Mentors remote contracted staff
• Demonstrates agility to meet client needs
• Maintain coding credentials as required by credentialing agency
• Maintain professional competence as evidenced through attendance in continuing education programs and the like; hours per year dependent on credential(s) held

Requirements

• Coding credential required (RHIT, RHIA, CCS, CPC, optional additional CRC)
• Minimum of one year HCC coding experience required
• Working knowledge of medical necessity
• Knowledge of Medicare Advantage, Commercial, Medicaid, and PACE risk adjustment methodologies preferred but not required
• High level of concentration and precision
• Ability to use a variety of software tools and reporting
• Must be able to work independently

• Ability to work in a fast paced, complex organization, with regulated deadlines while providing consistent high quality results to multiple clients
• Manage coding department leads/managers and coders
• Manage coding recruitment partners
• Fluent and current with risk adjustment coding models and regulations/protocols
• Develop and manage on going coding resource and operational plans to support multiple lines of business while ensuring customer satisfaction, quality and performance metrics
• Daily monitoring of all coding activity to meet contracted Statement of Work and Service Level Agreements
• Strong internal and external communication skills
• Experienced presenter with ability to speak at conferences and with all clients
• Proven experience in working with all levels of leadership internally and externally
• Ownership of ongoing updates from Department of Health and Human Services (HHS/CMS) regulations, guidelines, and programs
• Oversee:
  • Team development of internal coding guidelines aligned with CMS and ICD10 coding guidelines
  • Coding managers development and delivery of all internal training
  • Coding managers development and reporting of all coder performance and quality measurements
• Develop Executive level dashboards to manage daily work and status
• Maintain approximately 2 hours/per week of coding with managers/leads
• Ensure coding staff adheres to all compliance and credential requirements

Requirements

• Health Information Management and or Coding Certification (s) /Certified Professional Coder with 10+ years of a combination of coding and management experience. CPC and/or CRC, RHIT/RHIA required
• HCC and ICD-10 coding experience in Medicare Advantage, Commercial, PACE and Medicaid Managed Care risk adjustment models
• High level of professionalism
• Experienced conference and client presentation skills
• Healthcare/Health Plan or Medicare/ACA background required
• Working knowledge of risk adjustment and government audits as demonstrated with health plans
• Minimum of 5 years demonstrated experience in Coding Leadership Role(s)
• Must be self-directed and strong business acumen
• Proficiency in Microsoft Office Suite and proprietary software tools
• Strong written and verbal communication internally and client facing
• Excellent organizational skills and priority setting for self, team, and client(s)
• Bachelor’s degree preferred
• Conference and client travel required throughout the United States- approximately 25%