Responsible to perform clinical medical record reviews to examine and assess all patient documentation in order
to ensure that clinical documentation describes the severity of illness of the patient, as evidenced in claims or
billing invoices submitted for HCP Medicare Advantage patients. Responsible for conducting validation audits for
diagnosis codes submitted by providers to health plans and overseeing compliance with clinical, coding and
documentation guidelines as it applies to Medicare Risk Adjustment Payment System.
- Responsible for quality and continuous improvement within the job scope.
- Responsible for all actions/responsibilities as described in company controlled documentation for this position.
- Contributes to and supports the corporation's quality initiatives by planning, communicating and
encouraging team and individual contributions toward the corporation's quality improvement efforts.
- Improve documentation practices to reflect quality and outcome scores
- Educate physicians and key healthcare providers regarding clinical documentation improvement and the
need for accurate and complete documentation in the health record.
- Obtain and promote appropriate clinical documentation through extensive interaction with physicians to
ensure that the documentation of the level of service rendered to the patient and the patient's clinical
complexity is complete and accurate.
- Perform remote and on-site paper or electronic medical chart review and clinical validation audits and
interpretation of medical documentation to ensure clinical support of all relevant coding based on CMS
Hierarchical Condition Categories (HCC) conditions that are applicable to Medicare Risk Adjustment
- Facilitate and obtain appropriate physician documentation for any clinical conditions or procedures to
support the appropriate severity of illness, expected risk of mortality, and complexity of care of the
- Collaborate under the supervision of the AMD and CHAPs Programs Medical Director to communicate and
coordinate reviews with physician office staff and provide findings related to the review, including any
follow-up action items or corrective actions as appropriate.
- Assess review data to determine areas of improvement for follow up physician training and
- Provides outreach education to providers and providers’ staff on CMS Hierarchical Condition Categories
(CHAPs) coding requirements.
- Utilize query process when code assignments are not straightforward or documentation is not clear for
- Clinician focused process design, data analysis, and improvement strategies to drive project execution for
high quality/high priority outcomes.
- Assess clinical aspects of medical record documentation to drive improvement and consistency in
application across Medical Group adult primary care and specialty clinics and among Affiliate primary care
- Document and establish or confirm guidelines applicable to all aspects of the CHAPS
- Responsible for file maintenance including entry into coding audit database for tracking and trending audit
- Collection of supporting medical record documentation for encounter data corrections.
- Identifies patients with high risk CMS Hierarchical Condition Categories (HCC) and refers cases for annual
follow-up care by disease management, case management, and primary care providers as appropriate for
- Identify coding patterns within the CHAPs coding review process to the CHAPs Manager and corrective
measures to compliance issues.
- Prepare work papers/spreadsheets to collect and support chart review findings.
- Ensure strict confidentiality of financial and medical records.
- Must have a minimum of 5 years’ clinical experience and/or extensive ICD-10 diagnostic knowledge or
successful completion of an accredited coding certificate program. CPC, CPC-H from AAPC or CCS-P, CCS
from AHIMA. (Initial demonstration and maintenance of continuing education/membership is required)
- Clinical degree (RN, MD, DO, other credential) or Bachelor’s degree in related field preferred; and/or
relevant equivalent and relevant work experience preferred.
KNOWLEDGE, SKILLS, ABILITIES
- Excellent organization and problem-solving skills required.
- Strong oral and written communication skills required.
- Advanced understanding of medical terminology, pharmacology, body systems/anatomy, physiology and
concepts of disease processes.
- Extensive knowledge of ICD-10-CM coding guidelines is required.
- Familiarity and understanding of CMS HCC Risk Adjustment coding and data validation requirements,
- Demonstrated ability to utilize a variety of electronic medical records systems.
- Advanced technical skills for use of MS Office (Excel, Word, Outlook and PowerPoint) as demonstrated
through successful completion of skills test.
- Valid driver’s license required.
- Working conditions are normal for an office environment.
- Local travel required.