PR-HEALTH PROFILE EVALUATOR at TPIS

, Puerto Rico, United States -

Full Time

Start Date

Immediate

Expiry Date

16 Jul, 26

Salary

15.0

Posted On

17 Apr, 26

Experience

0 year(s) or above

Remote Job

Yes

Telecommute

Yes

Sponsor Visa

Skills

Medical billing, ICD-9 coding, ICD-10 coding, Clinical documentation, Data entry, Auditing, Compliance, Health risk assessment, Reporting, Medical terminology

Industry

Education Administration Programs

Description

Regular/Non-Exempt Position Responsible for evaluating CHRA (Comprehensive Health Risk Assessment) forms received from Classicare policyholders and coding the documented clinical information according to the guidelines established by the Unit. ESSENTIAL FUNCTIONS: ● Performs coding of diagnoses documented in the CHRA (Comprehensive Health Risk Assessment) and registers the data into the appropriate application. Identifies and tells the Supervisor about areas of opportunity to avoid errors that reduce rejected data and may represent a risk to compliance with established coding guidelines. ● Works on post-payment audits of adjudicated claims based on the information contained in the Comprehensive Health Risk Assessment comparing it to the information required, following the operational guidelines established by the unit. ● Generates referrals through the electronic app used in the Unit with providers and/or billing representatives, related to CHRA document management, to guide them and/or request correction of medical diagnoses due to incorrect coding, and inadequate, ambiguous, or incomplete medical documentation. ● Processes adjustments received for corrections in the CHRA, following the established operational guidance. ● Identifies claims that require the support of the Claims and/or Providers department to be processed. ● Provides weekly, monthly, and quarterly reports to the supervisor on audits performed as required. MINIMUM QUALIFICATIONS: Education and Experience: Two (2) years of college education equivalent to sixty (60) approved credits from an accredited university or an Associate degree. At least one (1) year of medical billing experience with ICD-9 and ICD10 coding. OR Education and Experience: Associate degree in Health Information Management Technology from an accredited university. At least six (6) months of experience performing clinical billing and coding processes. Certifications/Licenses: Medical billing certification and/or ICD-9, ICD-10, and/or other health-related certifications preferred. Other: Knowledge of medical billing processes and ICD-9-CM, ICD-10-CM coding. Languages: Spanish - Intermediate (writing, conversational, comprehension, and reading) English - Intermediate (writing, conversational, comprehension, and reading) Job Type: Full-time

Responsibilities

The evaluator is responsible for coding clinical diagnoses from health risk assessment forms and entering the data into the system. They also conduct post-payment audits and generate referrals to providers to ensure documentation accuracy and compliance.