Clinical Review Specialist / Medical Coder

100% REMOTE

Description:
The Clinical Review Specialist will be responsible reviewing medical records to abstract ICD-10 codes that map to HCCs from a variety of different CMS Hierarchy models including Medicare Advantage, PACE, Commercial, and Medicaid CDPS model. In addition to abstracting diagnosis codes, the Clinical Review Specialist also audits medical records and validates entries that have been submitted to CMS
 

Responsibilities:

• Conducts onsite and remote audits of medical records (paper, EMR, hybrid)
• Adheres to compliance of Medicare, Medicaid, and Commercial risk adjustment guidelines with precision.
• Understands, respects, and applies client specific guidelines
• Adheres to audit and medical record review schedules to meet client expectations and government-regulated deadlines
• Shares trends (positive and constructive) with Coding Manager and Team Leads for client consultation/collaboration
• Regularly participates in peer review; provide and receive feedback
• Ensures accurate documentation to support all audits
• Assures adherence to and currency with internal and external regulatory guidelines:
  • CMS/HHS
  • DOH
  • HIPAA, HITECH, and Fraud Waste & Abuse
  • Medical coding protocols
• Provides clinical intellect and expertise to system analytics via project assignments as well as on an ad hoc basis
• Participates on client and prospect conference calls, presentations, and in-person meetings as needed
• Mentors remote contracted staff
• Demonstrates agility to meet client needs
• Maintain coding credentials as required by credentialing agency
• Maintain professional competence as evidenced through attendance in continuing education programs and the like; hours per year dependent on credential(s) held

Requirements:

• Coding credential required (RHIT, RHIA, CCS, CPC, optional additional CRC)
• Minimum of one year HCC coding experience required
• Working knowledge of medical necessity
• Knowledge of Medicare Advantage, Commercial, Medicaid, and PACE risk adjustment methodologies preferred but not required
• High level of concentration and precision
• Ability to use a variety of software tools and reporting
• Must be able to work independently

Established in 1995, w3r Consulting is an award-winning national leader, providing data management and analytics, technology consulting services, and talent solutions. We partner with a diverse range of businesses and organizations, including Fortune 500 companies spanning the automotive, financial, government, health care, insurance, and retail industries.