Risk Adjusment Clinical Reviewer
Risk Adjusment Clinical Reviewer
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Job Description
City/State
Doral FLWork Shift
First (Days)Overview:
AvMed a division of Sentara Health Plans in the Florida market is hiring a Risk Adjustment Clinical Reviewer. This is a hybrid position 2 days onsite in our Doral Office and 3 days remote.
Then Risk Adjustment Clinical Reviewer performs compliance activities focused on risk adjustment in accordance with Centers for Medicare & Medicaid Services (CMS) and U.S. Department of Health & Human Services (HHS). Performs prospective/retrospective medical record reviews (MMR) & CMS/HHS Risk Adjustment Data Validation (RADV) audits. Reviews provider coding for professional & inpatient/outpatient services to ensure capture of diagnostic conditions supported within the providers documentation for CMS/HHS Hierarchical Condition Categories (HCC).
Supports risk adjustment data validation (RADV) medical record retrieval vendor coding audits provider engagement & all risk adjustment ICD10CM codingrelated activities. Conducts annual risk assessments training monitoring & auditing control assessment reporting investigation root cause analysis and corrective action oversight. Performs vendor quality oversight audits; reviews and/or makes final coding determination for nonagreeable coding. Makes final decision on vendortovendor diagnosis coding rebuttal concerns. Serves as subject matter expert on risk adjustment diagnosis coding guidelines. Coordinates risk adjustment gap elimination with clinical and quality gap elimination Maintains a reasonable fluency in workings & financial implications of applicable risk adjustment models.
Education:
- Associate degree required in healthcare administration nursing health information management accounting finance or another related field.
Certifications:
One of the following certifications are required:
- Certified Professional Coder (CPC)
- Certified Outpatient Coder (COC)
- Certified Inpatient Coder (CIC)
- Certified Coding SpecialistPhysicianbased (CCSP)
- Certified Coding Specialist (CCS) Registered Health Information Technician (RHIT) or Registered Health Information Administrator (RHIA).
- Must obtain Certified Risk Adjustment Coder (CRC) certification within two years of employment.
Experience:
- 2 years of medical coding experience. In lieu of associates degree 4 years of medical coding experience required.
- Must have thorough knowledge and understanding of ICD10CM Official Coding Guidelines and AHA Coding Clinics.
- Oneyear previous experience with paper and/or electronic medical records required.
- Prefer oneyear experience with risk adjustment program in a Health Plan or Provider setting (i.e. physician office or hospital). Prefer previous experience with CMS HHS and/or CDPSRX Hierarchical Condition Categories (HCC) models. Prefer previous CMS and/or HHS Risk Adjustment Data Validation (RADV) experience.
Keywords: Talroohealth Plan Health Insurance coding CPC COC CIC CCSP CCS RHIT RHIA CRC ICD10
Legal Resources Plan
Colleagues have the opportunity to earn an annual discretionary bonus ifestablished system and employee eligibility criteria is met.
Sentara Health is an equal opportunity employer and prides itself on the diversity and inclusiveness of its close to an almost 30000member workforce. Diversity inclusion and belonging is a guiding principle of the organization to ensure its workforce reflects the communities it serves.
In support of our mission to improve health every day this is a tobaccofree environment.
For positions that are available as remote work Sentara Health employs associates in the following states:
Alabama Delaware Florida Georgia Idaho Indiana Kansas Louisiana Maine Maryland Minnesota Nebraska Nevada New Hampshire North Carolina North Dakota Ohio Oklahoma Pennsylvania South Carolina South Dakota Tennessee Texas Utah Virginia Washington West Virginia Wisconsin and Wyoming.
Employment Type
Full-Time
