Utilization Review Analyst

Job Summary 

This position helps to ensure clinical documentation integrity and ICD-10-CM coding by engaging and educating providers.? The role will perform these duties in accordance with ICD-10 CM coding guidelines, internal coding protocols and CMS guidance.? This role will support provider education and training related to diagnostic documentation and coding.?  

Reviews concurrent medical record for compliance including completeness and accuracy for severity of illness, risk, and quality using documentation strategies.  Completes accurate and timely record review to ensure the integrity of documentation compliance.  Recognizes opportunities for documentation improvement using strong critical-thinking skills. Uses critical thinking and sound judgment in decision making keeping quality considerations in balance with regulatory compliance. 

Essential Functions: 

• Collaborates with interdisciplinary teams including, physicians, nurse practitioners, PA's, and the department managers for revenue integrity, coding and data quality. 
• Perform Clinical Documentation Improvement medical record reviews based on organizational priorities.   
• Develop and lead provider education regarding trends and areas of opportunity regarding compliant documentation and coding practices.  
• Responsible for the full life of our advanced therapy patients which includes identification, provider education, coordination with vendors, monitoring patient progress, billing/coding,  ensuring proper reimbursement, and payment for associated products. 
• Assist Clinical and Operations’ departments by making recommendations for further process improvements to enhance documentation and coding quality goals and outcomes. 
• Remain current on ICD-10-CM coding guidelines, AHA Coding Clinic Guidance and CMS Risk Adjustment guidance. 
• Support clinical orientation efforts and ongoing staff development and assessment.  
• Report issues regarding non-compliance to Clinical Operations for education, corrective action plan and escalation as appropriate.  
• Oversight of all state reports, logs, and vaccines to ensure compliance; other duties as assigned. 

Desired Skills and Experience: 

• RN or LPN License preferred
• Bachelor’s degree in healthcare related field preferred
• Wound Care Experience preferred
• Strong critical reasoning, decision-making and problem-solving skills to analyze situations 
• Organizational skills and attention to details to handle multiple tasks, short deadlines, frequent interruptions, and shifting priorities in support of changing company objectives 
• CDI or risk adjustment coding/auditing experience preferred 
• Demonstrated experience developing and delivering provider education preferred 
• Effective verbal and written communication including ability to present ideas and concepts effectively to providers, management, and other members of the team. 

Competencies and Attributes: 

• Strong analytical and problem-solving skills. 
• Strong oral and written communication skills 
• Strong organization and time management skills 
• Ability to work independently 
• Ability to multi-task