American Health Partners

Utilization Review Nurse

• Assess the medical necessity, quality of care, level of care and appropriateness of health care services for plan members
• Identify placement settings that offer the lowest level of restriction and greatest level of autonomy for the members based upon medical necessity
• Conduct outreach to requesting providers which can include specialty physicians, ancillary providers and institutions to gather the appropriate/necessary clinical data
• Apply clinical review criteria, guidelines, and screens in determining the medical necessity of health care services against the clinical data provided
• Certify cases that meet clinical review criteria, guidelines and/or screens
• Consult with physician when reviews do not meet clinical review criteria, guidelines, and screens
• Refer cases to other professionals internally, including case management and medical consultation when indicated
• Adhere to accreditation, contractual and regulatory timeframes in performing all utilization management review processes
• Ensure that the Director of Medical Management or designee is made aware of any potential risk management issues in a timely manner
• Other duties as assigned

Medical Billing and Coding

• Review medical records, patient medical history and physical exams, physician orders, progress notes, consultation reports, diagnostic reports, operative and pathology reports, and discharge summaries to verify accuracy, completeness, specificity, and appropriateness of diagnosis codes
• Assist with validation audits to evaluate medical record documentation to ensure coding accurately reflects and supports relevant coding based on the ICD-10 code submitted to CMS for reimbursement
• Interpret medical documentation to ensure all relevant coding based on CMS Hierarchical Condition Categories (HCC) conditions applicable to Medicare Risk Adjustment reimbursement initiatives is captured
• Develop tools and metrics to improve accuracy and completeness of coding and documentation
• Provide a high level of customer service to internal and external clients by meeting and/or exceeding expectations including quality and productivity standards
• Escalate appropriate coding audit issues to management as required
• Participate in and support ad-hoc coding audits as needed
• Support ongoing programs which minimize organizational risk in the event of a Risk Adjustment Data Validation (RADV) Audit
• Work assigned coding projects to completion
• Other duties as assigned

Utilization Review Nurse

Medicare Risk Adjustment Coding Specialist