Premium Management Pre-Audit Specialist

GENERAL DESCRIPTION: Performs internal and external audits of Independent Contractors and Providers following the established work plan, monitoring compliance with documentation and clinical coding rules. Identifies situations that may represent a risk in case of a Risk Adjustment audit conducted by CMS (Center for Medicare and Medicaid Services). ESSENTIAL FUNCTIONS: • Perform clinical coding and RADV (Risk Adjustment Data Validation) audits, according to the work plan established for internal and external clients. • Identifies areas of opportunity to reduce audit risk and maximize risk adjustments, and situations that represent a risk to compliance with coding guidelines, by referring them to management as required. Visit physicians and IPA’s offices for medical record review and conduct educational intervention (in person, virtual, or by telephone calls) to suppliers, and providers as part of the discussion of audit results. • As required, establish written and telephone communication with providers and IPA Administrations regarding inquiries and target information requested related to best coding practices, documentation, and diagnosis validation. • Develop and deliver presentations to IPA Administrators and providers based on the Unit work plan and other identified needs. • Evaluate the referrals received by the different units of the company to guide providers, GMPs (General Medicine Practitioners), and internal clients, among others, on the rules of documentation and clinical coding.. • Responds to referrals, either through a call, coordination of educational intervention, or emails, among others, to identify the need with the corresponding departments. • Documents the results of audits performed. Keeps an updated record of such audits. • Provides advice to clients regarding the results of audits. Recommends and implements action and improvement plans, according to identified findings. • Reports to management on audits performed, as required. • Participate in the department's educational plan. • Keeps up to date with all coding guidelines established by the different accrediting agencies, such as Medicare, AHIMA (American Health Information Management Association), and AMA (American Medical Association), among others. Always complies with the coding ethics 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 areas. At least one (1) year of experience performing audits in diagnosis coding, medical records review, clinical information extraction, medical terminology, and risk identification in operational areas. “Proven experience may be replaced by previously established requirements.” Certifications / Licenses: As apply: Certified Coding Associate (CCA) or Certified Coding Specialist (CCS) or Certified Coding SpecialistPhysician (CCS-P) or Medical Billing is preferred. A Driver's License valid in the Commonwealth of Puerto Rico is required. Others: A car in good condition and available to move to different Puerto Rico locations. Available to work extended hours, holidays, and weekends as the operations require. Languages: Spanish – Intermediate (comprehensive, writing and verbal) English – Intermediate (comprehensive, writing and verbal)