AvMed, a division of Sentara Health Plans in the Florida market, is hiring a Risk Adjustment Clinical Reviewer. This is a hybrid position, 2 days onsite in our Doral Office and 3 days remote.

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 required in healthcare administration, nursing, health information management, accounting, finance, or another related field.

Certifications:

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.

Keywords: Talroo-health Plan, Health Insurance, coding, CPC, COC, CIC, CCS-P, CCS, RHIT, RHIA, CRC, ICD10