DaVita CDI Specialist - CHAP's in LAS VEGAS, Nevada

CDI Specialist - CHAP's

Description

Overview:

The HCC Clinical Reviewer/Clinical Documentation Improvement Specialist performs clinical medical record reviews to examine and assess all patient documentation in order to ensure that clinical documentation describes the severity of illness of the patient, as evidenced in claims or billing invoices submitted for HCPN Medicare Advantage patients. This is accomplished by performing prospective, concurrent and retrospective review of patient medical records. The Clinical Reviewer is responsible for conducting validation audits for diagnosis codes submitted by providers to health plans and overseeing compliance with clinical, coding and documentation guidelines as it applies to Medicare Risk Adjustment Payment System.

Essential Functions:

  • Responsible for quality and continuous improvement within the job scope.

  • Improve documentation practices to reflect quality and outcome scores

  • Educate physicians and key healthcare providers regarding clinical documentation improvement and the need for accurate and complete documentation in the health record.

  • Obtain and promote appropriate clinical documentation through extensive interaction with physicians to ensure that the documentation of the level of service rendered to the patient and the patient's clinical complexity is complete and accurate.

  • Responsible for all actions/responsibilities as described in company controlleddocumentation for this position.

  • Perform remote and on-site paper or electronic medical chart review and clinical validation audits and interpretation of medical documentation to ensure clinical support of all relevant coding based on CMS Hierarchical Condition Categories (HCC) conditions that are applicable to Medicare Risk Adjustment reimbursement initiatives.

  • Facilitate and obtain appropriate physician documentation for any clinical conditions or procedures to support the appropriate severity of illness, expected risk of mortality, and complexity of care of the patient.

  • Collaborate under the supervision of the AMD and CHAPs Programs Medical Director to communicate and coordinate reviews with physician office staff and provide findings related to the review, including any follow-up action items or corrective actions as appropriate.

  • Assess review data to determine areas of improvement for follow up physician training and communication.

  • Provides outreach education to providers and providers’ staff on CMS Hierarchical Condition Categories (CHAPs) coding requirements. This includes technical guidance in identifying and resolving issues such as incomplete or missing documentation, ambiguous or nonspecific documentation or codes that do not conform to approved coding principles/guidelines.

  • Utilize query process when code assignments are not straightforward or documentation is not clear for coding purposes.

  • Clinician focused process design, data analysis, and improvement strategies to drive project execution for high quality/high priority outcomes.

  • Assess clinical aspects of medical record documentation to drive improvement and consistency in application across Medical Group adult primary care and specialty clinics and among Affiliate primary care offices.

  • Document and establish or confirm guidelines applicable to all aspects of the CHAPS

  • Responsible for file maintenance including entry into coding audit database for tracking and trending audit results.

  • Collection of supporting medical record documentation for encounter data corrections.

  • Identifies patients with high risk CMS Hierarchical Condition Categories (HCC) and refers cases for annual follow-up care by disease management, case management, and primary care providers as appropriate for assessment/intervention.

  • Identify coding patterns within the CHAPs coding review process to the CHAPs Manager and corrective measures to compliance issues.

  • Prepare work papers/spreadsheets to collect and support chart review findings.

  • Ensure strict confidentiality of financial and medical records.

  • Works directly with management to establish policies and procedures for continuous clinical documentation improvement.

Qualifications

Education:

  • Clinical degree (RN, MD, DO, other credential) or Bachelor’s degree in related field preferred; and/or relevant equivalent and relevant work experience preferred.

Experience:

  • Minimum: 1-3 years of experience

  • Preferred: 5 or more years of experience

Knowledge, Skills, and Abilities

  • Excellent organization and problem-solving skills required. Strong oral and written communication skills required.

  • Advanced understanding of medical terminology, pharmacology, body systems/anatomy, physiology and concepts of disease processes

  • Extensive knowledge of ICD-10-CM coding guidelines is required.

  • Familiarity and understanding of CMS HCC Risk Adjustment coding and data validation requirements, preferred.

  • Ability to maintain and establish working relationships with physicians and support staff.

  • Demonstrated ability to utilize a variety of electronic medical records systems.

  • Ability to manage significant workload and to work professionally and efficiently under pressure meeting established deadlines with minimal supervision.

  • Demonstrated ability to communicate clearly and effectively with a wide variety of individuals at all levels of the organization.

  • Strong time management and project management skills.

  • Must possess high degree of accuracy, efficiency and dependability.

  • Excellent written and oral communicationfor representation of clear and concise results.

  • Advanced technical skills for use of MS Office (Excel, Word, Outlook and PowerPoint) as demonstrated through successful completion of skills test.

  • Valid driver’s license required.

  • Local travel required.

Excellent organization and problem-solving skills required. Strong oral and written communication skills required.Advanced understanding of medical terminology, pharmacology, body systems/anatomy, physiology and concepts of disease processesExtensive knowledge of ICD-10-CM coding guidelines is required.Familiarity and understanding of CMS HCC Risk Adjustment coding and data validation requirements, preferred.Ability to maintain and establish working relationships with physicians and support staff.Demonstrated ability to utilize a variety of electronic medical records systems.Ability to manage significant workload and to work professionally and efficiently under pressure meeting established deadlines with minimal supervision.Demonstrated ability to communicate clearly and effectively with a wide variety of individuals at all levels of the organization.Strong time management and project management skills.Must possess high degree of accuracy, efficiency and dependability.Excellent written and oral communicationfor representation of clear and concise results.Advanced technical skills for use of MS Office (Excel, Word, Outlook and PowerPoint) as demonstrated through successful completion of skills test.Valid driver’s license required.Local travel required.

DaVita Medical Group manages and operates medical groups and affiliated physician networks in California, Colorado, Florida, Nevada, New Mexico, Pennsylvania and Washington. A leading independent medical group in America, DaVita Medical Group has over two decades of experience providing coordinated, outcomes-based medical care in a cost-effective manner. As of December 31, 2016, DaVita Medical Group’s teammates, employed clinicians and affiliated clinicians provided care for approximately 1.7 million patients. DaVita Medical Group’s leadership development initiatives and social responsibility efforts have been recognized by Fortune, Modern Healthcare, Newsweek and WorldBlu.

DaVita Medical Group is an equal opportunity/affirmative action employer. As such, DaVita Medical Group makes hiring decisions solely on the basis of qualifications and experience, and without regard to age, race, color, religion, sex, gender identity, sexual orientation, national origin, disability or protected veteran status.

We maintain a drug-free workplace and perform pre-employment substance abuse testing and background verification checks.

DaVita Medical Group will consider qualified applicants who have criminal histories in a manner consistent with the law.

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Primary Location NV-LAS VEGAS - 89119

Req ID: 330650