Clinical Consultant I

Overview

The Clinical Consultant support Clinical Services teams in the validation of quality and processes consistency on the CPE editing engine.  

Provides support and subject matter expertise on Coding Validation (CV) to both clients and internal stakeholders during the planning, implementation, go-live, transition to operational team, and through the duration of the contract. Clearly understands and articulates CV concepts and policies. Collaborates with internal teams to provide meaningful input on CV processes, improvements, and support to maximize value and service for clients. Supports internal teams with preparation of new policy presentations and appeals management process. Supports validation of quality and process consistency including customization requests, payment policies, pre and post testing, and UAT testing.

Responsibilities

Client facing Coding Validation support:

• Act as a liaison for clinical information between internal partners and external customers.
• Provide resources to facilitate client understanding of Coding Validation policies and concepts.
• Respond to client inquiries in a timely manner in compliance with policy and procedures.
• Review and analyze CV related client inquiries and Change Requests for clarity of intent, assessing impact of decisions for affected policies, and communicating effectively with the client to address questions or clarify information.
• Provide support and resources to clients for provider abrasion issues.
• Review and provide written and/or verbal explanation of CV coding concepts.
• Resource to client for CV related quality issues
• Appropriately and effectively communicate quality review results and revisions (if applicable) to clients when they occur.
• Provide action plans to mitigate future issues as needed with Quality Team in close internal collaboration.

 Add Value to Internal Teams:

• Proactively offer benefit of CV knowledge and experience
• Work collaboratively with Client Teams to develop and maintain excellent client relationships.
• Collaborate and provide input from a client-based perspective on changes in edit configuration, updates to existing rules, and development of new editing.
• Assist the Clinical Content Team with feedback from a client perspective on new trends and application of new rules.
• Work with Quality, Training, and Operations Teams as needed to facilitate any updates in CV review guidelines, effectively communicate changes in client specific review, and address other CV client issues in an accurate and timely manner.
• Support resource for the Clinical Services team on Coding Validation implementations, including reviewing test claims, and internal go-live support.
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