Job Description

Title: Clinical Coder

Location:  REMOTE

Responsibilities:

• These are individuals who take chart data from the HEDIS process and abstract the necessary information for loading into an accredited HEDIS tool.
• Responsible for working with appropriate departments in the areas of compliance, process improvement and member/provider satisfaction for all product lines.
• Review, researches and responds to customer complaints relating to quality of medical care and service.
• Recommends and/or implements process improvements related to the potential of quality medical care and service.
• Serves as a resource regarding accreditation standards including NCQA standards and continuous quality improvement principles.
• May coordinate accreditation activities on behalf of the organization. Perform special studies per audits, conducting office site visits and medical records reviews, ensuring resolution of member/provider complaints in timely manner.
• Coordinating credentialing and re-credentialing activities to include QM information, and support preparations for regulatory audits.

Essential Job Functions:

• Develops, manages process improvement initiatives from member/providers to include detailed data analysis, process analysis, report generation and documentation.
• Conduct, collect and analyze data from office site and/or medical record reviews to continually improve the care and service to members and coordination with the credentialing and quality improvement programs to achieve and maintain accreditation.
• Monitor changes, corrections and clarifications in applicable regulatory/accrediting body requirements and make adjustments to the compliance plan.
• Conduct annual audits, identify gaps, communicate results and re-audit

Minimum Qualifications:

• Current state RN license or a Bachelors degree in a Healthcare-related field.
• 2 - 5 years experience in a clinical setting.

Preferred Qualifications:

• An understanding of Total Quality Management (TQM) concepts, techniques, process and outcome measurements
• An understanding of statistics is also preferred in order to analyze various reports and validate study methodologies HEDIS (Healthcare Effectiveness Data Information Set) and/or quality measures