Job Description

Job Description Summary Responsible for conducting retrospective medical reviews to assess medical record documentation and monitoring submitted codes on claim/encounters for Medicare Risk Adjustment. How will you make an impact & Requirements Clinical Document Improvement Specialist Responsible for conducting retrospective medical reviews to assess medical record documentation and monitoring submitted codes on claim/encounters for Medicare Risk Adjustment. Primary duties include, but are not limited to: Conducts retrospective medical record and claims review to assess medical record documentation practices and accuracy/sufficiency of policies and procedures. Verifies accuracy/appropriateness of submitted diagnosis codes based on medical record documentation looking at both ways 1) appropriate detail in the medical record is not captured in what is reported, and 2) when reported information is not supported by details in the medical record. Identifies and recommends coding best practices to address unsupported additions/deletions, inconsistencies/discrepancies. Updates and develops policies and procedures and training/educating collateral to reflect best practices. Conducts on-going review, monitoring and communications to promote and ensure adherence to established protocols and best practices. Reviews documentation of well visits (annual well visits and other routine and preventative visits) including the use of appropriate modifiers for HEDIS scoring accuracy. Conducts on-going review of medical records/practice notes to validate improvement, identify any new/additional opportunities to improve medical record-keeping, code more accurately, ensure on-going accuracy of submitted codes and accurate risk scoring and continues to verify coding accuracy and completeness to ensure compliance. Requirements: Requires minimum of 2 years experience coding all types of medical records (including Medicare Risk Adjustment) in a physician practice setting or large group practice. Current Certified Professional Coder certification (CPC, CPC-H, CCS, or CCS-P) required. Additional experience in procedural clinical coding preferred. Clinical experience or background (e.g. RN, LPN, foreign medical graduates) preferred. ~ For the Carelon Health business unit only, the above requirements do not apply. The following are the Carelon Health job requirements for this role: Requires a minimum of 2 years' experience with all types of medical records (including Medicare Risk Adjustment and evaluation and management coding) in a physician practice setting or large group practice, and includes educating providers on clinical documentation needs. Certified Clinical Documentation Specialist (CCDS, CCDS-O), Certified Documentation Expert Outpatient (CDEO), or Certified Documentation Improvement Professional (CDIP) required. Current Certified Professional Coder certification (CPC, CPC-H, CCS, CCS-P or CRC) preferred. Additional experience in diagnostic clinical coding preferred. Clinical experience or background (e.g. RN, LPN, foreign medical graduates) preferred. Travels to worksite and other locations as necessary. Compensation: $79,440K - $119,160K/annual salary & bonus eligible

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