Clinical Reviewer - Ma - Full Time

Summary/Objective

The Clinical Reviewer uses their medical knowledge to identify and address quality gaps and assist with the coordination of care for the Clinic’s patients. This role produces, abstracts, and submits data, and works from portals, spreadsheets, and databases to support quality projects and Value Based Services contracts. Clinical Reviewers are responsible for contacting patients telephonically to schedule needed care or perform monitoring.

Essential Functions

• Accurately abstracts data from Watson Clinic's EHR and hospital EHR to support quality initiatives and projects with both internal and external entities.
• Accurately enter clinical data into payer portals, spreadsheets, and/or the database to track status of data abstraction projects and close care gaps.
• Accurately utilizes Watson Clinic protocols, care coordination guidelines, and patient-specific provider treatment plans to: Ensure patients have access to clinic providers and needed appointments. Educate Watson Clinic patients on managing conditions/diseases. Promote patient self-management. Assist with coordinating health care services and site of care concerns, and communicate with physician-lead Care Teams.
• Follow program guidelines to assist physicians with documentation of patient interactions in an electronic platform for risk adjustment coding purposes.
• Works in a team environment with risk adjustment coders, RNs, and analysts to ensure providers are following proven processes to appropriately increase their quality ratings and HCC risk scores.
• Maintains excellent communication skills with patients to promote adherence to each patient's specific provider treatment plan

Required Education and Experience: High school diploma or GED. Completion of an accredited Medical Assistant program. Medical Assistant Certification must be obtained within 90 days of employment. Ability to use filters, attach documents, and work with a variety of Microsoft applications is required.

Preferred Education and Experience: Coding experience or certification, or some college is preferred. Experience and understanding of quality metrics in an outpatient clinic setting is highly preferred.

Additional Eligibility Qualifications: Ability and initiative to become familiar with industry and individual health plan incentive program quality measurement specifications related to group practices, e.g., National Committee for Quality Assurance (NCQA) Health Effectiveness Data Information Set (HEDIS).