Medical Coder

Outpatient Clinical Documentation Specialist

The Risk Adjustment CDS will provide clinically based prospective concurrent and retrospective reviews of medical records for WellSense of members enrolled in value-based agreements to evaluate risk adjustment capture based on clinical documentation. The Risk Adjustment CDS will review risk adjustment gap lists for members including suspect conditions and perform chart reviews to determine clinical validity of open gaps. The Risk Adjustment CDS will utilize Physician documentation queries to communicate clinical indicators to Physicians/Other Qualified Health Care Providers in preparation for up-coming visits and/or in identifying patients that need to be seen for a visit. The goal of the risk adjustment reviews includes facilitation of appropriate physician documentation of care delivery to accurately reflect patient severity of illness and risk of mortality. Specific reviews are both determined internally and by requirements/requests of external payers or regulatory agencies and play a significant role in reporting quality of care outcomes and in obtaining accurate and compliant reimbursement based on patient risk.

Position: Outpatient Clinical Documentation Specialist

Schedule: Full Time

Essential Responsibilities / Duties:

• Perform pre-visit planning chart review for up-coming patient appointments
• Identify clinical indicators for suspect high-risk conditions to accurately capture patient disease burden and improve patient outcomes and reduce hospitalizations
• WellSense contract performance and improve provider clinical documentation
• Create compliant Risk Adjustment CDI queries based on clinical indicators found in chart review
• Manage CDI query provider engagement respond to provider questions assess clinical documentation to ensure documentation integrity and compliance with reported disease burden
• Identify areas of risk and opportunity in provider documentation and coding in order to uphold clinical documentation integrity to ultimately reduce healthcare resource utilization
• Identify documentation education for Risk Adjustment/HCC documentation and coding
• Track and Trend CDI findings and provider engagement for clinical documentation education purposes for any specialty within the hospital system
• Potential to support on additional types of Risk Adjustment reviews
• Additional duties as assigned

Job Requirements

Required Education and Experience:

• Bachelors degree in Nursing or Health Information Management is required
• Minimum 5 years related experience working on the payer or provider side in Risk Adjustment Validation including prospective documentation reviews and pre-visit planning
• Or Equivalent combination of education and experience

Preferred Education and Experience:

• Population Health experience
• NCQA/HEDIS CDS experience

Certifications Licenses Registrations Required:

• Certified Risk Adjustment Coder

Certifications Licenses Registrations Preferred:

• CCDS CCDS-O CPMA CDEO RHIT/RHIA

Knowledge Skills & Abilities (KSAs):

• Knowledge of care delivery documentation systems and related medical record documents.
• Knowledge of age-specific needs and the elements of disease processes and related procedures.
• Strong broad-based clinical knowledge and understanding of pathology/physiology of disease processes.
• Excellent written and verbal communication skills.
• Excellent critical thinking skills.
• Excellent understanding of Compliant Query processes in Risk Adjustment/Outpatient CDI.
• Excellent understanding of ICD10CM coding and guidelines
• Excellent understanding of risk adjustment methodology and value based care.
• Working knowledge of CPT/HCPCS level II Coding
• Ability to develop and maintain employee and medical staff relationships.
• Ability to work independently in a time-oriented environment.
• Computer literacy and familiarity with Microsoft 365 and basic office equipment.
• Competency in tracking outcomes of risk adjustment/CDS activities.
• Ability to adapt to changes in the workload to work independently and effectively prioritize work assignments
• Knowledge of DxCG Risk Adjustment methodology (MassHealth Medicaid)