Valor Healthcare is looking for a Medical Reviewer to join our team on a PRN or per diem basis supporting arbitration of Medicare/Medicaid evaluations.

Schedule: This position is typically 4 hour a week with flexible hours depending on candidate's availability. Although, there may be a few instances where meetings may take place during the work day.

The focus of Risk Adjustment Data Validation (RADV) is on reviewing medical record documentation to verify diagnoses submitted by Medicare Advantage (MA) organizations for payment under Medicare Part C. The medical review process includes:

• Medical Record Intake: MA organizations are required to submit requested enrollee medical records to the RADV Centralized Data Analytics Tool-Modernized (CDAT-M). Administrative staff and certified coders review records that reject out of the automated intake process to determine if required medical record validation criteria for diagnosis abstraction are met.
• Medical Record Diagnoses Abstraction: Certified medical record ICD-9 and ICD-10-CM (International Classification of Diseases, Ninth & Tenth Revision, And Clinical Modification) coders and the Physician Reviewer evaluate the medical records submitted by the MA organizations and abstract diagnoses in accordance with the ICD-9 and ICD-10-CM coding guidelines. Familiarity with encoder software functionality and code abstraction is preferred.
• Medical Record Review Appeals Support: MA organizations who wish to dispute discrepant CMS-HCC results may submit appeals, following CMS official guidelines for this process. Certified medical record ICD-9 and ICD-10-CM coders and the Physician Reviewer reexamine disputed medical records for Center for Medicare/Medicaid Services (CMS) during the appeals process.