Risk Adjustment Clinical Reviewer

City/State

Work Shift

Overview:

Status: Full-timepermanent position (40 hours)

Standard working hours: 8am to 430pm EST, M-F

Location: This is a hybrid position, 2 days onsite in AvMed Doral Office, 3470 NW 82nd Ave Suite 1100, Doral, FL 33122, and 3 days remote.

Job Profile Summary

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 provider's 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 ICD-10-CM coding-related 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 non-agreeable coding. Makes final decision on vendor-to-vendor 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 in healthcare administration, nursing, health information management, accounting, finance, or another related field REQUIRED

Certifications/Licenses:

One of the following certifications are REQUIRED:

• Certified Professional Coder (CPC)

• Certified Outpatient Coder (COC),

• Certified Inpatient Coder (CIC),

• Certified Coding Specialist-Physician-based (CCS-P),

• 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 associate's degree, 4 years of medical coding experience REQUIRED

• Must have thorough knowledge and understanding of ICD-10-CM Official Coding Guidelines and AHA Coding Clinics.

• One-year previous experience with paper and/or electronic medical records REQUIRED.

• Prefer one-year 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 CDPS+RX Hierarchical Condition Categories (HCC) models. Prefer previous CMS and/or HHS Risk Adjustment Data Validation (RADV) experience.

AvMed is one of Florida's oldest and largest not-for-profit health plans headquartered in Miami,Florida with over 50 years of experience focused on providing quality cost-effective plans andexcellent Member services.

AvMed is part of Sentara Healthcare, an integrated, not-for-profit health care delivery system celebrating more than 130 years of history with 30,000 employees, 12 hospitals in Virginia and Northeastern North Carolina, and the Sentara Health Plans division serving more than 1.2 million members in Virginia and Florida.

Our success is supported by a family-friendly culture that encourages community involvement and creates unlimited opportunities for development and growth.

Be a part of an excellent healthcare organization that cares about our People, Quality, Patient Safety, Service, and Integrity. Join a team that has a mission to improve health every day and a vision to be the healthcare choice of the communities that we serve!

To apply, please go to www.sentaracareers.com and use the following as your Keyword Search: JR-78545

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Talroo - Health Plan, Health Insurance, coding, CPC, COC, CIC, CCS-P, CCS, RHIT, RHIA, CRC, ICD-10, Risk Adjustment, Florida, Doral, Centers for Medicare & Medicaid Services (CMS), U.S. Department of Health & Human Services (HHS), medical record reviews (MMR), Risk Adjustment Data Validation (RADV), Certified Professional Coder (CPC), Certified Outpatient Coder (COC), Certified Inpatient Coder (CIC), Certified Coding Specialist-Physician-based (CCS-P), Certified Coding Specialist (CCS), Registered Health Information Technician (RHIT), Registered Health Information Administrator (RHIA), AHA, HHS Hierarchical Condition Categories (HCC)

Sentara Health is an equal opportunity employer and prides itself on the diversity and inclusiveness of its close to an almost 30,000-member 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 tobacco-free 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.