• Risk Adjustment Clinical Reviewer

    Job Locations US-RI-Smithfield
    Req No.
    Medical Expense Management
    Regular Full-Time
  • Overview

    The Risk Adjustment Clinical Reviewer role supports, compiles and cultivates data and supporting medical documentation for Risk Adjustment and related Factors. Key lead in community outreach to providers and members in closing diagnosis gaps through in home assessments, or other face to face interactions with Primary or Specialty Care Physicians. Partner with Internal and External stakeholders to ensure upstream and downstream processes align in support of Case/Care Management, Utilization Manager, Health @ Home or Nursing Home Rounding Programs.


    • Year-round chart abstraction/Medical Records review including record request, documentation and appropriate storage
    • Lead in RADV or other audit performance, roadmaps and audit preparation
    • Act as Risk Adjustment Medical liaison SME for internal and external stakeholders
    • Assist coding staff in mapping processes for HCC Risk Scores and Validation
    • Assist Manager with design of additional clinical interventions to support increase in Risk Adjustment Scores
    • Able to conduct quantitative and qualitative analysis of data to identify needed areas of improvement
    • Maintain and enhance the relationships between the Plan and the Provider Community in support of Accurate Risk Scores
    • Collaborate with Internal and External Provider Community to reduce abrasion regarding record request and ensure information sharing
    • Support Manager in planning, organizing and prioritizing assignments to comply with performance standards, corporate goals and established State or Federal Guidelines
    • Ability to support strategic direction for program operations, goals, metrics, tasks, timeframe and appropriate reporting and timing related to all National HCC Activities.
    • Identify and apply best practices to ensure accuracy of risk adjustment payments in all markets served by Neighborhood Health Plan
    • Monitor risk adjustment relates activities including but not limited to risk adjustment program payments, encounter data submission and return files to ensure all tasks are completed in a timely manner and achieve expected outcomes
    • Develop tools to be used to improve accuracy of coding and documentation that meet State and National Standards
    • Consistently exhibit behaviors and foster relationships with peers and internal stakeholders

    Regulatory Oversight and Quality Assurance:

    • Support the company’s quality assurance programs that monitor, audit and improve the quality of provider medical record documentation, diagnosis coding and the coding work of staff and vendors as relates to risk adjustment.
    • Support strategies for effective and regular monitoring and auditing to identify risks, improve quality and reduce risk stemming from CMS RADV audits.

    Provider Engagement, Training and Support

    • In Partnership with Manager , support internal departments in financial analysis, on error rates associated with coding accuracy to ensure data is complete and accurate prior to submission to external agencies.
    • In conjunction with other departments, develop and implement programs that will enhance provider training and education of the HCC Risk Adjustment Process, Proper Medical Record Documentation and Diagnosis Accuracy.

    Analysis and Use of Results

    • Support and document analysis of risk adjustment programs including ROI, productivity, quality, risk score/ revenue impact at the plan and provider group level.
    • Utilize analysis to identify trends and opportunities for improvement, new strategies and further program development
    • Support Manager with Medical Management on the integration of prospective programs into care management processes and promotes the use of risk adjustment programs to help facilitate care management.
    • Collaborate with Manager to project and monitor the impact of coding programs on CMS revenue for budgets and plans

    Enterprise Risk Adjustment

    • Support Manager in driving enterprise-wide risk adjustment initiatives.


    Qualifications Required:

    • Associate and/or Bachelor Degree in Nursing from an accredited University
    • Active Rhode Island License as Licensed Practical Nurse or Registered Nurse
    • 2-4 years related experience in Managed Care, Public Health or Related Field
    • Previous experience in risk adjustment activities in a Medicare, CA or provider organization to include RAPs, EDPS, EDGE Server, RADV Audits and all CMS, State and other regulatory Guidelines.
    • Strong knowledge of EMR tools and ability to retrieve records associated with audit or review criteria.
    • Understanding of Risk Score impact to plan and prioritization of data to close diagnosis gaps.
    • Understanding of base of data points associated with the end to end process of plan payment
    • Experience in gathering requirements and create policies, procedures and workflows to drive a successful Risk Adjustment program.
    • Knowledge of claims coding and payment methodology, associated with a Health Plan domain.
    • Proficient in CPT, HCPCS, and related Hierarchical Condition Coding (HCC) Methodologies

    Qualifications Preferred:

    • Experience in Project Management
    • System application such as Amysis or Health Edge
    • Previous experience in Medicare Advantage, MMP or Exchange Programs
    • Advanced skills with Microsoft Office (Project, Word, Excel, PowerPoint, Outlook)

    Organizational Competencies:

    • Judgment and Decision Making
    • Gets Results
    • Collaboration and Teamwork
    • Business Awareness
    • Customer Focus

    Job Specific Competencies:

    • Attention to Detail
    • Relationship Building & Networking
    • Continuous Quality Improvement
    • Planning & Organizing
    • Problem Solving & Analysis

    FDR Oversight:

    • Business Lead Level:
      • In the role of business lead for assigned FDR; incumbent is responsible to complete comprehensive oversight and monitoring of their vendor that incorporates the following elements: efficient and effective operations; compliance with laws, regulations, policies, procedures; and other company performance issues designed to reduce risk and add value to the company
    • Travel Expectations:
      • Local Travel Required


    Neighborhood is an Affirmative Action and Equal Opportunity Employer and all qualified applicants will receive consideration for employment without regard to race, color, religion, gender, sexual orientation, national origin, genetic information, age, disability, veteran status or any other legally protected basis.


    Neighborhood is committed to ensuring individuals with disabilities and/or those who have special needs participate in the workforce and are afforded equal opportunity to apply for jobs. If you would like to contact us regarding the accessibility of our Website or need assistance completing the application process, please contact us at recruiting@nhpri.org.


    Neighborhood is an EOE M/F/D/V and an E-Verify Employer


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