Performs audits of pre-visit medical record reviews to identify chronic conditions reported in prior years and conditions that lack supporting documentation.
Evaluates suggestions or clinical alerts presented by Prospective Chart reviewers, ensure that these suggestions meet specificity requirements to support clinical indicators and in compliance with Risk Adjustment documentation standards.
Conducts review and communicates feedback to professionals such as Clinical Chart Reviewers and third-party vendors.
Responds to questions submitted by Prospective Chart reviewers.
Document detailed audit findings including all errors and missed opportunities in the Prospective chart reviews.
Correlate activities, processes and HCC results/ metrics to evaluate outcomes.
Assist in developing workflows, curriculum and policies and procedures related to the Pre-visit Medical Record review team.
Other Job Functions:
Understand, adhere to, and implement the Company s policies and procedures.
Provide excellent customer services skills, including consistently displaying awareness and sensitivity to the needs of internal and/or external clients. Proactively ensuring that these needs are met or exceeded.
Take personal responsibility for personal growth including acquiring new skills, knowledge, and information.
Engage in excellent communication which includes listening attentively and speaking professionally.
Set and complete challenging goals.
Demonstrate attention to detail and accuracy in work product.
Required Qualifications:
Minimum Experience
2+ years of clinical experience required
5+ year of chart review and medical coding/auditing experience required
Advanced level of clinical knowledge associated with chronic disease states required
Education/Licensure:
Medical doctor or Nurse required
Coding Certification through AHIMA or AAPC required
CPC or CPMA preferred
Skills and Abilities:
Ability to be a team player and exercise initiative in responding to provider requests and concerns in a helpful and courteous manner
Provider contracting and customer service techniques General understanding of the health care industry, ideally the provider relations field-desired
Excellent interpersonal and telephone communication skills are required
Exercise attention to detail; ability to provide accurate data entry
Ability to work under pressure with minimal supervision, multi-task, complete projects in a timely fashion and meet deadlines a must Excellent analytical, problem solving and organizational skills a must
Strong communication skills both written and verbal to work with multiple internal and external clients in a fast-paced environment Ability to work with mathematical concepts such as probability and statistical inference
Ability to apply concepts such as fractions, percentages, ratios, and proportions to practical situations
Ability to apply principles of logical or scientific thinking to a wide range of intellectual and practical problems
Ability to create and maintain documents using Microsoft Office (Word, Excel, Outlook, PowerPoint)
