Evaluador(A) De Perfiles De Salud

Evaluador(A) de Perfiles de Salud

GENERAL DESCRIPTION:

Responsible for evaluating CHRA (Comprehensive Health Risk Assessment) forms received from Classicare policyholders and coding the documented clinical information according to the guidelines established by the Unit.

ESSENTIAL FUNCTIONS:

• Performs coding of diagnoses documented in the CHRA (Comprehensive Health Risk Assessment) and registers the data into the appropriate application. Identifies and informs the Supervisor about areas of opportunity to avoid errors that reduce rejected data and may represent a risk to compliance with established coding guidelines.

• Works on post-payment audits of adjudicated claims based on the information contained in the Comprehensive Health Risk Assessment comparing it to the information required, following the operational guidelines established by the unit.

• Generates referrals through the electronic app used in the Unit with providers and/or billing representatives, related to CHRA document management, to guide them and/or request correction of medical diagnoses due to incorrect coding, and inadequate, ambiguous, or incomplete medical documentation.

• Process adjustments received for corrections in the CHRA, following the established operational guidance.

• Identifies claims that require the support of the Claims and/or Providers department to be processed.

• Provides weekly, monthly, and quarterly reports to the supervisor on audits performed as required.

• 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: Two (2) years of college education equivalent to sixty (60) approved credits from an accredited university or an Associate degree. At least one (1) year of medical billing experience with ICD-9 and ICD-10 coding.

OR

Education and Experience: Associate degree in Health Information Management Technology from an accredited university. At least six (6) months of experience performing clinical billing and coding processes.

"Proven experience may be replaced by previously established requirements."

Certifications / Licenses: Medical billing certification and/or ICD-9, ICD-10, and/or other health-related certifications preferred.

Other: Knowledge of medical billing processes and ICD-9-CM, ICD-10-CM coding.

Languages:
Spanish – Advanced (comprehensive, writing and verbal)
English – Advanced (comprehensive, writing and verbal)

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