Premium Management Pre-Audit Specialist

MCS Puerto Rico; San Juan (PR); On-site; USD 65,000 - 85,000; Full time

Job summary

MCS Puerto Rico is seeking a detail-oriented RADV audits specialist to perform internal and external audits of Independent Contractors and Providers, ensuring compliance with documentation and clinical coding rules.

The role involves visiting physician offices, delivering trainings, communicating with IPA administrations, and reporting findings to management while staying current with CMS/AHIMA/AMA guidelines.

Qualifications

• Bachelor's degree in health-related area.
• At least 1 year of audit experience performing diagnosis coding, medical records review, and risk identification.
• Certifications such as CCA/CCS/CCS-P or Medical Billing preferred. A valid driver's license.

Responsibilities

• Perform clinical coding and RADV audits according to the work plan.
• Identify opportunities to reduce audit risk and educate providers or IPA administrators.
• Communicate with providers and IPA administrations regarding inquiries on coding and documentation.
• Develop and deliver presentations to IPA Administrators and providers.
• Evaluate referrals to guide providers on documentation and coding rules.
• Document audit results and keep updated records.
• Advise clients on audit findings and implement improvement plans.
• Report audits to management and participate in educational plans.
• Stay up to date with coding guidelines from CMS, AHIMA and AMA.

Skills

Auditing

Medical records review

Clinical coding knowledge

Communication skills

Education delivery

Education

Bachelor's degree in health-related field

Job description

GENERAL DESCRIPTION:

Performs internal and external audits of Independent Contractors and Providers following the established work plan, monitoring compliance with documentation and clinical coding rules. Identifies situations that may represent a risk in case of a Risk Adjustment audit conducted by CMS (Center for Medicare and Medicaid Services).

Regular
Exempt

ESSENTIAL FUNCTIONS:

• Perform clinical coding and RADV (Risk Adjustment Data Validation) audits, according to the work plan established for internal and external clients.
• Identifies areas of opportunity to reduce audit risk and maximize risk adjustments, and situations that represent a risk to compliance with coding guidelines, by referring them to management as required. Visit physicians and IPA’s offices for medical record review and conduct educational intervention (in person, virtual, or by telephone calls) to suppliers, and providers as part of the discussion of audit results.
• As required, establish written and telephone communication with providers and IPA Administrations regarding inquiries and target information requested related to best coding practices, documentation, and diagnosis validation.
• Develop and deliver presentations to IPA Administrators and providers based on the Unit work plan and other identified needs.
• Evaluate the referrals received by the different units of the company to guide providers, GMPs (General Medicine Practitioners), and internal clients, among others, on the rules of documentation and clinical coding.
• Responds to referrals, either through a call, coordination of educational intervention, or emails, among others, to identify the need with the corresponding departments.
• Documents the results of audits performed. Keeps an updated record of such audits.
• Provides advice to clients regarding the results of audits. Recommends and implements action and improvement plans, according to identified findings.
• Reports to management on audits performed, as required.
• Participate in the department's educational plan.
• Keeps up to date with all coding guidelines established by the different accrediting agencies, such as Medicare, AHIMA (American Health Information Management Association), and AMA (American Medical Association), among others. Always complies with the coding ethics standards established by AHIMA.

ADDITIONAL FUNCTIONS:

• Must comply fully and consistently with all company policies and procedures, with local and federal laws as well as with the regulations applicable to our Industry, to maintain appropriate business and employment practices.
• May carry out other duties and responsibilities as assigned, according to the requirements of education and experience contained in this document.

MINIMUM QUALIFICATIONS:

Education and Experience: Bachelor's Degree in Health-related areas. At least one (1) year of experience performing audits in diagnosis coding, medical records review, clinical information extraction, medical terminology, and risk identification in operational areas.

“Proven experience may be replaced by previously established requirements.”

Certifications / Licenses:

As apply: Certified Coding Associate (CCA) or Certified Coding Specialist (CCS) or Certified Coding Specialist-Physician (CCS-P) or Medical Billing is preferred. A Driver's License valid in the Commonwealth of Puerto Rico is required.

Others:

A car in good condition and available to move to different Puerto Rico locations. Available to work extended hours, holidays, and weekends as the operations require.

Languages:

Spanish – Intermediate (comprehensive, writing and verbal)

English – Intermediate (comprehensive, writing and verbal)

“We are an Equal Employment Opportunity Employer and take affirmative action to recruit Protected Veterans and Individuals with Disabilities.”