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
• Preferably located in Rochester, NY

We are seeking a highly organized and detail-oriented individual to join our Account Management team. Managing multiple client accounts, the Account Manager’s responsibilities include maintaining a thorough knowledge of our business and offerings, managing and strengthening client relationships, identifying new business opportunities, and coordinating with internal teams to deliver on internal and external client expectations.

Responsibilities

• Ability to work in a fast paced, complex organization, with regulated deadlines while providing effective account management support to multiple clients
• Managing multiple clients in different time zones while developing strong relationships to ensure customer satisfaction
• Develop client work plans
• Coordinate and manage all client activities aligned to work plans
• Daily monitoring of all aspects of current client activity to meet contracted Statement of Work and Cognisight work flows
• In depth knowledge and ability to articulate all interdependencies associated with client reports
• Strong communication skills to conduct client calls with all levels of leadership
• Develop and deliver client Webinars
• Own all client status’ and provide accurate updates, gaps and gap closing plans regularly to Operation Huddles
• Staying apprised of the Department of Health and Human Services (HHS) regulations, guidelines, and programs and ability to weave into all work flows and articulate with clients

Requirements

• Healthcare/Health Plan or Medicare/ACA background strongly preferred
• Must be self-directed and escalate concerns with potential solutions
• Minimum of 3 years demonstrated experience in Account/Client Management
• High level of professionalism
• Bachelor’s degree required
• Working knowledge of risk adjustment and government audits as demonstrated with health plans
• 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)
• Minimal client travel required
• Must be located in Rochester, NY