Chart Review Specialist - Medicare-Medicaid Insurance - Medical Records - Risk Adjustment - Fallon Health

About us:

Fallon Health is a company that cares. We prioritize our members—always—making sure they get the care they need and deserve. Founded in 1977 in Worcester, Massachusetts, Fallon Health delivers equitable, high-quality, coordinated care and is continually rated among the nation’s top health plans for member experience, service, and clinical quality. We believe our individual differences, life experiences, knowledge, self-expression, and unique capabilities allow us to better serve our members. We embrace and encourage differences in age, race, ethnicity, gender identity and expression, physical and mental ability, sexual orientation, socio-economic status, and other characteristics that make people unique. Today, guided by our mission of improving health and inspiring hope, we strive to be the leading provider of government-sponsored health insurance programs—including Medicare, Medicaid, and PACE (Program of All-Inclusive Care for the Elderly)— in the region. Learn more at fallonhealth.org or follow us on Facebook, Twitter and LinkedIn.

The Chart Review Specialist primary responsibility is to review, analyze and report on FCHP patient charts for the purpose of validating regulatory Risk Adjustment scores. The Chart Review Specialist will collect diagnostic details and documentation observations from multiple chart sources to validate diagnostic profiles.   The CRS must demonstrate the ability to oversee the chart review life cycle from scheduling access, collecting images, coding chart and updating data software.  The CRS must have the ability to code on both and INP and OPD basis. Will participate in monthly Inter-rater reliability discussions to develop and enforce coding P&Ps and define Coding Standards and best practices. Accept assignment from the Manager. Maintain strong interdepartmental relationships. Light travel may be required.   

Chart Review ~85%

• Perform retrospective chart reviews for designated populations & volumes
• Own chart review process from start to end
• Collect documentation feedback and submit to Manager for provider education efforts
• Update risk adjustment software with all relevant chart review observations
• Meet or exceed daily chart review targets

Regulatory Compliance ~10%

• Develop and present concise provider-specific feedback  for targeted providers and provider groups.
• Identify diagnoses for submission as well as deletion in support of claims adjustment efforts
• Ensure chart reviews and related claims adjustment activities completed within regulatory data submission timelines and within  CMS Coding and Coding Clinic guidelines 

Corporate Project Support ~5%

• Participate in corporate projects and subgroup meetings.  Complete analyses  related to corporate projects and business needs as needed.
• Participate in regional Coding Chapter meetings

• HCC coding knowledge preferred
• Ability to abstract and code diagnosis information from the medical record.
• Medical terminology
• Requires technical expertise in ICD-9-CM or ICD-10-CM
• Basic MS Office skills; Excel and or Access

License/Certifications: CPC-A, CRC, CPC-C or CPC-P is required

Education:  High School diploma or GED required.  Associated degree preferred.  

Fallon Health provides equal employment opportunities to all employees and applicants for employment and prohibits discrimination and harassment of any type without regard to race, color, religion, age, sex, national origin, disability status, genetics, protected veteran status, sexual orientation, gender identity or expression, or any other characteristic protected by federal, state or local laws.