Providers Education Specialist

GENERAL DESCRIPTION: Provides education to internal and external clients on operational topics that promote efficiency in the process executed by our providers and business partners, such as the Risk Adjustment payment model “CMS-HCC”, ensuring best practices in coding standards and clinical documentation within the medical records and electronic tools. ESSENTIAL FUNCTIONS: •Evaluates the referrals received by various internal units (e.g. Premium Management Operations, Providers, Clinical Review, Regional Medical Directors, among others), and identifies the educational needs of providers, internal customers. Establishes the educational plan to be followed within the unit to meet the operational goals. • Develops presentations and educational materials based on requests from other departments, our unit’s work plan, and other identified needs. • Provides educational activities to internal and external clients according to the designed work plan, requests from other departments and other identified educational needs through the different modalities available (in-person, phone, virtual, and online, etc.). • Visits medical offices to educate providers and their staff on how to improve their clinical documentation and coding process. • Provides education to IPAs administrators and their PCPs in mass activities according to our work plan and requests from the provider department. • Conducts educational interventions with providers based on the risk classification and findings identified as part of the Premium Management Department Risk Adjustment Data Validation Audit (RADV) program. • Provides support to other MCS departments to enhance providers and administrative staff education on other topics such as: HEDIS quality measures, Annual Health Risk Assessment (CHRA), CAHPS HOS surveys and the Care Model (MOC). • Receives and evaluates referrals according to the identified areas of opportunity to reduce rejected data in Encounter Data System (EDS), audit risk and risk adjustments maximization, and situations that pose a risk to coding compliance. • Serves as a liaison between the Education unit and the provider, outpatient clinic MIS department, Billing Staff, and/or medical office representatives to ensure correct code assignment through diagnosis validation. • Establishes written and/or telephone communication with providers and/or billing representatives regarding inquiries and/or referrals for information related to best coding practices, documentation, and diagnosis validation. Keeps control and records of educational interventions and consultations performed. • Submits weekly, monthly, and quarterly reports of educational interventions to the unit Supervisor as required. Keeps up to date with all coding guidelines established by the different accrediting agencies, such as Medicare, AHIMA, AMA, and so on. Always complies with the ethical coding standards established by AHIMA. • Must comply fully and consistently with all company policies and procedures, with local and federal laws as well as with the regulations applicable to our Industry, to maintain appropriate business and employment practices. • May carry out other duties and responsibilities as assigned, according to the requirements of education and experience contained in this document. MINIMUM QUALIFICATIONS: Education and Experience: Bachelor’s degree in health-related fields. At least two (2) years of experience in extracting diagnoses and procedures and interpreting medical records for coding inpatient and outpatient medical services; working in hospitals, medical offices, and insurance companies, among others; and facilitating educational presentations. OR Education and Experience: Associate’s degree in Health Information Management Technology or health-related fields. At least four (4) years of experience in extracting diagnoses and procedures, interpreting medical records for coding inpatient and outpatient medical services, working in hospitals, medical offices, and insurance companies, and facilitating educational presentations. “Proven experience may be replaced by previously established requirements.” Certifications / Licenses: • Valid driver’s license in the Commonwealth of Puerto Rico is required. • Preferably a clinical coding certificate, such as CCA (Certified Coding Associate), CCS (Certified Coding Specialist), or CCS-P (Certified Coding Specialist-Physician). • Preferably a certificate in Medical Billing. Other: Available to travel around the Island, Vieques, and Culebra; work extended hours, holidays, and weekends, as required. Languages: Spanish – Intermediate (comprehensive, writing, and verbal) English – Intermediate (comprehensive, writing, and verbal)