Job Title: Risk Adjustment and Clinical Specialist
Reports To: Director of Network and Clinical Services
Summary: The Risk Adjustment and Clinical Coordinator is a member of the CSMS-IPA value-based care team and is responsible to engage with physician offices to ensure optimal disease coding and documentation and patient management with emphasis on care transitions, disease management, and HEDIS/STAR quality measure performance.
Essential DUTIES AND RESPONSIBILITIES:
• Develop and maintain detailed understanding of HEDIS and STAR measures to help organizational success in these areas
• Develop knowledge base of all health plan collaboration goals, population health tools, and performance measures
• Conduct on-site and virtual visits with healthcare providers to educate on population health tool entries, coding guidelines, and audit required documentation
• Responsible for collection of all medical record requests from health plan partners
• Analyze network and evaluate network HCC capture and develop initiatives to improve documentation and coding
• Coordinate with Physician Network Specialists to ensure effective working relationships with physicians and practices to achieve metric outcomes for cost and quality
• Serve as a resource to Physician Network Specialists in analysis of practices high risk/high cost patients as requested by team
• Attend and facilitate clinical meetings with the health plans as needed
• Oversee clinical care rounds with physicians/staff and health plan partner (as appropriate)
• Staff liaison to the Clinical Care Management Committee
• Implement clinical/quality initiatives aligned with CSMS-IPA collaboration goals and objective
• Educate and encourage appropriate referrals by physicians and their staff on available payer sponsored programs such as disease and complex case management
• Write articles for newsletter as needed
• Document and record all practice contacts and tasks in electronically
• Other duties as assigned
Education, Knowledge and Skills:
Preferred candidate is a licensed practical nurse with 5 years’ experience in the healthcare field and/or is a certified coder (AAPC or AHIMA). Candidate should possess knowledge of Medical Coding, patient centered medical homes, value-based care, physician practice administration, HEDIS and Star quality measures.
Skill set must include:
• Read and analyze population health reports.
• Able to work independently and as a team member
• Clinical Program design
• Computer proficiency in word office suite
• Strategic thinking
• Highly organized
• Excellent written and oral skills and capability
• Interpersonal Skills
• Ability to problem solve
• Public speaking
Licensure and Certification:
• Licensed Practical Nurse preferred
• Medical Coder Certification preferred or achieved within 12 months of employment
• Valid CT driver’s license and employee must maintain, at employee’s expense, an automobile for the provision of the duties, and responsibilities described herein, as well as automobile liability insurance coverage with limits of not less than $100,000/$300,000.
Business office environment with regular travel statewide to physician practices and meetings.
To apply for a posted position please send a resume and cover letter to email@example.com.
Join the CSMS-IPA team of professionals who work to fulfill our mission of promoting high-quality, cost-effective medical care that is physician driven, financially sustainable and valued by health care stakeholders. CSMS-IPA is an Equal Opportunity Employer. Every employee has an important role in our operations and we value the abilities and experience that each team member brings to our company.