Job Summary:

• Proactively identifying and resolving issues noted during data management which impacts the overall timelines and informs the appropriate Client team members. 
• Engages the Data Lead or Manager to assist in the resolution of more complex issues. 
• Understands how the issues of a single study can impact the overall project.
• Responsible for the development of data review plan and processes for data management that can be easily accessible by all protocol team members. 
• Possesses a strong knowledge of Clinical Study Report concepts and applies them for defining tools for data clean-up and defining plan for completing database lock activities. 
• Apply nationally-recognized clinical criteria and guidelines to determine the medical necessity of inpatient admissions, outpatient procedures, and other healthcare services.
• Consult with physicians or refer cases to others, when indicated.
• Collects and review documents to support the organization’s risk adjustment initiatives, which results in improving quality of care. 
• Participate in a multi-disciplinary team to improve the quality of healthcare for individuals and populations.

Skills on Resume:

• Issue Resolution (Hard Skills)
• Data Management (Hard Skills)
• Data Strategy (Hard Skills)
• Clinical Assessment (Hard Skills)
• Physician Collaboration (Soft Skills)
• Risk Adjustment (Hard Skills)
• Quality Advocacy (Soft Skills)
• Impact Analysis (Hard Skills)

Job Summary:

• EPIC based chart reviews, read and interpret clinical documentation from open/closed medical records and align with metrics of established criteria.
• Analyze data and identify trends, patterns, and/or opportunities for improvement
• In-process and outcomes reporting preparation.
• Participates in orientation and continuing education and updates and maintains knowledge and skills related to specific areas of expertise
• Performs clinical review for in-patients using established criteria.
• Reviews open/closed charts, analyzes and interprets regulations from NSQIP (National Surgical Quality Improvement Program), STS (Society of Thoracic Surgeons), NCDR (Cardiovascular Data Registry), NYS Department of Health and Hospital Rules and Regulations.
• Performs electronic medical record review using established criteria from NYS DOH, CMS and/or STS and NCDR. 
• Medical record review may include abstracting a specific patient data on various diagnoses/procedures.
• Perform accurate reviews within set timeline.
• Collaborate with leadership to provide formal feedback through performance development process.

Skills on Resume:

• EPIC Chart Reviews (Hard Skills)
• Data Analysis (Hard Skills)
• Reporting Preparation (Hard Skills)
• Continuing Education (Soft Skills)
• Clinical Review (Hard Skills)
• Regulatory Compliance (Hard Skills)
• Medical Record Abstracting (Hard Skills)
• Leadership Collaboration (Soft Skills)

Job Summary:

• Reviews medical records, patient medical history and physical exams, physician orders, progress notes, consultation reports, diagnostic reports, operative and pathology reports, and discharge summaries, lab results, pharmacy results, supplemental HCC and HRA capture
• Review for clinical indicators and query providers to capture the severity of illness of the patient
• Identify for the Physician gaps and opportunities for the Member visit and documentation
• Identify gaps in care and participate in HCC reconciliation procedures to support education and proper documentation
• Identify HCC’s that can be attested to in conjunction with proper CMS documentation
• Conducts timely review of assigned medical records. 
• Apply the appropriate ICD-10 code to the highest specificity in the disease hierarchy to the MA and ACA optimization initiative.
• Travel to multiple medical facilities as needed to complete onsite charts review, as needed.
• Develops comprehensive, provider-specific plans to address physician performance towards documentation, coding patterns, Stars/HEDIS metrics and improve their outcomes by resolving risk adjustment and/or quality gaps.

Skills on Resume:

• Record Review (Hard Skills)
• Clinical Querying (Hard Skills)
• Gap Analysis (Hard Skills)
• HCC Reconciliation (Hard Skills)
• ICD-10 Coding (Hard Skills)
• Timely Review (Hard Skills)
• Site Visits (Hard Skills)
• Performance Plans (Hard Skills)

Job Summary:

• Ensures compliance with all applicable CMS regulations and guidance relative to coding and documentation guidelines for Risk Adjustment Reviews.
• Analyzes reports to identify and report documentation and coding trends and opportunities 
• Collaborates with internal and external teams to ensure the providers documentation and diagnostic code selection are appropriate and to the most appropriate level of specificity and recommend improvements
• Travels to assigned provider offices as needed for meetings, education, training, and record retrieval and encounter submission. 
• Retrieves and submits medical records from EMR and or paper charts to the plan through appropriate methods.
• Conducts prospective claim reviews to establish clinical integrity.
• Processes select claim appeals for clinical appropriateness.
• Performs retrospective provider reimbursement, utilization pattern/trend and target analysis.
• Manages the internal review and external workflow/process for the Medicare Optimization Function.

Skills on Resume:

• CMS Compliance (Hard Skills)
• Trend Analysis (Hard Skills)
• Team Collaboration (Soft Skills)
• Provider Travel (Hard Skills)
• Record Retrieval (Hard Skills)
• Claim Reviews (Hard Skills)
• Appeals Processing (Hard Skills)
• Workflow Management (Hard Skills)