The Health Plan of San Mateo (HPSM), a managed care health plan, seeks a full time Clinical Documentation Improvement (CDI) Specialist to utilize clinical acumen and coding expertise to conduct concurrent and retrospective reviews of medical records for the purpose of evaluation and improvement of the clinical and medical record documentation in compliance with industry best practices and federal, state, and accrediting entities. The CDI Specialist collaborates with internal stakeholders and community medical groups to make clinical documentation improvements that result in accurate, comprehensive documentation that reflects appropriate risk scores and quality indicators. This role dedicates time to both the Medicare Risk Adjustment and Quality Improvement (QI) functions based on shifting annual business need(s) and ongoing regulatory or reporting requirements.

The essential duties and responsibilities will include the following:

•Support Medicare Risk Adjustment and Quality Improvement (QI) functions in all work related to medical record collections and review, clinical documentation improvement activities, data tracking, and internal and external educational efforts.
•Review and assess the accuracy, completeness, specificity and appropriateness of ICD-10 diagnosis codes (with an emphasis on HCC and RxHCC-related codes) based on medical record documentation and in accordance with established coding guidelines and clinical principles.
•Conduct medical record collection, data abstraction and over-read (validation) in support of annual Health Effectiveness Data Information Set (HEDIS) and participate in related activities, as needed.
•Independently identify and/or complete requests for periodic chart audits to identify coding and documentation improvement opportunities related to internal HPSM initiatives, HPSM vendor initiatives, or activity by network providers. This may involve cross-functional or vendor-facing communications and/or traveling to physician offices or medical groups to review medical records and provide training or feedback.
•Ongoing medical and facility site reviews (FSRs) and physical accessibility reviews (PARs); perform site reviews, enter data into database, produce and distribute results to providers; conduct pre-contractual reviews with providers under contracting consideration.
•Clinical investigations into Potential Quality of Care Issues (PQIs) in coordination with relevant departments and community providers/entities.
•Develop materials, tools, and resources to provide internal and external clinical documentation improvement trainings or educational sessions.
•Conduct medical record review activities and support organizational decision-making and risk management related to Risk Adjustment Data Validation (RADV) Audits.
•Complete chart reviews or audits following appropriate coding or project guidelines.
•Maintain a comprehensive tracking and management tool for assigned medical record reviews.
•Develop, implement, and follow up with corrective action plans.
•Conduct ad hoc medical record review in support of business needs.
•Other duties as assigned.


Education and Experience: A valid California license as a Registered Nurse (RN) with 5+ years of relevant nursing experience in a managed care plan, primary care, or quality improvement setting. Bachelor’s degree in Nursing preferred. 3+ years of experience coding ICD-10-CM in a risk adjustment or quality environment. Certified Professional Coder (CPC), Certified Outpatient Coder (COC) or Certified Coding Specialist (CCS) required. Advanced proficiency in ICD-10 coding principles required. Certified Risk Adjustment Coder (CRC) certification strongly preferred. Coding credentials must be current and maintained during employment.

Knowledge of: Medical record review methodologies and resources (e.g., AHIMA, Coding Clinic), Medicare Risk Adjustment principles (e.g., HCC, RxHCC, payment methodologies), and documentation evaluation protocols (e.g., MEAT, TAMPER) required. Risk Adjustment Data Validation (RADV) Audits and/or Health Effectiveness Data Information Set (HEDIS) reporting strongly preferred. Medicare Advantage and Medi-Cal managed care programs.
Quality improvement principles and techniques, including training methodologies and facilitation. Personal computers and proficiency in Microsoft Office Suite applications, including Outlook, Word, Excel, Access and PowerPoint.

Ability to: Evaluate medical records and other health care-related data or reporting.
Plan, organize and lead data or chart collection activities. Maintain accurate records and confidentiality of sensitive medical information. Prioritize and accurately complete tasks within established timeframes and regulatory deadlines. Present clinical, statistical and technical data in a clear and understandable manner utilizing appropriate aids to multiple audiences, including network providers. Establish and maintain strong consultative and coaching relationships. Adapt to changes in requirements/priorities for daily and specialized tasks in the context of a cross-functional and matrixed role. Cross-train in support of new or ongoing Quality Improvement (QI) and Medicare Risk Adjustment business needs. Assume responsibility and exercise appropriate judgment in decision-making within the scope of the role. Work cooperatively with others.

Compensation and Benefits:

Starting Compensation Range: – Depending on Experience
Benefits Information: Excellent benefits package offered, including HPSM paid premiums for employee’s Medical, Dental and Vision coverage. Employee pays a small portion of the dependent premiums (5%) for medical and dental benefits. Additional HPSM benefits include fully paid life, AD&D, and LTD insurance; retirement plan (HPSM contributes equivalent of 10% of annual compensation); holiday and vacation pay; tuition reimbursement plan; onsite fitness center and more.

How to Apply:

Application Process: To apply, submit a resume and cover letter with salary expectations to: Health Plan of San Mateo, Human Resources Department, 801 Gateway Blvd., Suite 100, South San Francisco, CA 94080 or via email: careers@hpsm.org or via fax: (650) 616-8039. File by: Continuous until filled. The Health Plan of San Mateo is proud to be an Equal Opportunity Employer and encourages minority candidates of all backgrounds to apply.
Submissions without a Cover Letter and Salary Expectations may not be considered.

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