Clinical Reviewer

Overall Purpose

The Clinical Reviewer is responsible for reviewing the medical records to identify Medicare Risk Adjusting diagnoses that have 1) been previously identified 2) are embedded but not evaluated and 3) potential clinically inferred. The Clinical reviewer will create a clinical summary flag identifying the conditions and the probable support for those conditions. Additionally the reviewer will abstract HEDIS quality gaps specific for the patient based on specific documentation criteria.

Essential Functions

• Conduct detailed medical record reviews to identify risk-adjustable conditions per CMS guidelines.
• Create patient condition summaries using internal tools (e.g. Patient 360 Excel macros).
• Identify and flag opportunities for clinical documentation improvement (CDI).
• Upload supporting evidence for the closure of quality gaps (e.g. HEDIS).
• Collaborate with providers and clinical teams to improve documentation accuracy and completeness.
• Help drive provider engagement and education around risk adjustment and documentation standards.
• Maintain production standards and meet established quality and timeliness goals.

Knowledge Skills and Abilities

• Strong clinical understanding and ability to interpret complex medical records
• Knowledge of CMS Risk Adjustment models (e.g. HCC ACO REACH RAF scoring)
• Familiarity with ICD-10 documentation guidelines and MEAT criteria
• Skilled in Microsoft Office particularly Excel and Outlook
• Detail-oriented highly organized and capable of managing multiple tasks independently
• Strong interpersonal and communication skills to work effectively with clinical and non-clinical teams
• Comfortable interacting with providers coding teams and operations staff
• Motivated team player with a positive attitude and accountability for outcomes
• Able to work in a deadline-driven environment and maintain productivity metrics

Experience

• Understanding of CMS Risk Adjustment compliance rules and regulations
• Understanding of CMS Risk Adjustment models
• Understanding of ICD10 MRA documentation guidelines

Education

• Physician (DO MD) Nurse Practitioner Physician Assistant Nurse (RN LPN) Coder CDI certification or similar experience
• Current coding certification through AAPC or AHIMA preferred but not required

Pay Range: $80000 - $95000 based on experience

About P3

People. Passion. Purpose.

At P3 Health Partners our promise is to guide our communities to better health unburden clinicians align incentives and engage patients. We are a physician-led organization relentless in our mission to overcome all obstacles by positively disrupting the business of health care transforming it from sickness care into wellness guidance. If you are passionate about your work; eager to have fun; and motivated to be part of a fast-growing organization then you should consider joining our team.