Physician Medical Reviewer

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.

• The Physician Reviewer(s) shall have experience in the health insurance industry, a utilization review firm, or health care claims processing organization and interpreting clinical documentation.
• Practicing medicine for a minimum of three (3) years as a licensed and board-certified doctor of medicine or osteopathy
• Communicating and working with important program stakeholders, such as with physician groups, beneficiary organizations, and/or congressional offices.
• The Physician Reviewer(s) must have knowledge of the Medicare program, and be capable of effectively interpreting and resolving disagreements regarding clinical guidelines.
• Working knowledge of ICD-9-CM and ICD-10-CM code sets, official coding guidelines and clinics, and encoder software use in code abstraction are preferred.
• The Physician Reviewer(s) must be a board-certified Doctor of Medicine or a Doctor of Osteopathy in a specialty recognized by the American Board of Medical Specialties.
• The Physician Reviewer(s) must have an active, valid and unrestricted license and must be currently licensed to practice in at least one US state.

We consider applicants for all positions without regard to race, color, religion, creed, gender, national origin, age, sexual orientation, gender identity, disability or medical or veteran status in accordance with federal law. In addition, Valor Healthcare. complies with applicable state and local laws prohibiting discrimination in employment in every jurisdiction in which it maintains facilities.