About Fallon Health
Founded in 1977, Fallon Health is a leading health care services organization that supports the diverse and changing needs of those we serve. In addition to offering innovative health insurance solutions and a variety of Medicaid and Medicare products, we excel in creating unique health care programs and services that provide coordinated, integrated care for seniors and individuals with complex health needs. Fallon has consistently ranked among the nation’s top health plans, and is accredited by the National Committee for Quality Assurance for its HMO, Medicare Advantage and Medicaid products. For more information, visit fallonhealth.org.
Brief Summary of Purpose:
The Chart Review Specialist I’s 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 I will collect diagnostic details and documentation observations from multiple chart sources to validate diagnostic profiles. The CRS I must demonstrate the ability to oversee the chart review life cycle from scheduling access, collecting images coding chart and updating data software. The CRS I must have the ability to code on both and INP and OPD basis. Will participate in bi-weekly Inter-rater reliability discussions to develop and enforce coding P&Ps and define Coding Standards and best practices. Accept assignment from Chart Review Coordinator and Nurse Chart Review Coordinator as appropriate. Maintain strong interdepartmental relationships.
This position is located in Worcester, MA.
- Perform retrospective chart reviews for designated populations & volumes
- Own chart review process from start to end
- Collect documentation feedback and submit to Nurse Chart Review Coordinator and Chart Review Coordinator for provider education efforts
- Update risk adjustment software with all relevant chart review observations
- Meet or exceed daily chart review targets
- 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
- Participate in corporate projects and subgroup meetings. Complete analyses related to corporate projects and business needs as needed.
- Participate in regional Coding Chapter meetings
Education: High School diploma or GED required. Associated degree preferred.
Certification: CPC-A, CPC-C or CPC-P is required
- Completion of 135 Internship/Externship hours in the health care industry.
- Medical billing/claims processing ,medical record auditing, medical record review, Medical record abstraction or combination
- Medical terminology
- ICD-9 & ICD-10 compliant
- Basic MS Office skills; Excel and or Access
Job is located in Worcester, MA.