Clinical Review Specialist

GENERAL DESCRIPTION: Responsible for performing clinical quality assessments and documentation reviews across the Classicare provider network to ensure compliance with the Center for Medicare and Medicaid Services (CMS), Healthcare Effectiveness Data and Information Set (HEDIS), and internal standards. Validates diagnoses, assesses documentation quality, and promotes accurate risk adjustment coding practices. Provides targeted education to providers, helping them improve documentation practices and align with regulatory and organizational requirements. ESSENTIAL FUNCTIONS: Develop and maintain a detailed work plan outlining scheduled and completed clinical review activities.

Coordinate with provider offices to request medical records and schedule onsite or virtual visits for documentation review. Conducts quality assessments, HEDIS evaluations, and Premium Management reviews, adhering to established company policies and procedures. Review medical records to validate diagnosis coding accuracy and ensure clinical documentation supports submitted diagnoses. Communicate findings directly with providers and/or office administrators, offering constructive feedback and clinical education as needed. Identify documentation gaps or educational opportunities and deliver customized training on clinical documentation improvement, accurate coding, and compliance with CMS and HEDIS guidelines.

Recommend and develop Corrective Action Plans (CAPs) for providers who fall short of documentation and coding standards. Serve as a liaison between providers and the Premium Management department, maintaining ongoing, professional communication to support collaborative improvement. Report activities, including completed audits and education provided, to the management. Identify and escalate potential risks or issues related to premium management processes and suggest improvements to enhance service quality and performance. Adhere strictly to ethical standards, HEDIS/STARS specifications, and regulatory guidelines established by Medicare, Medicaid, National Committee for Quality Assurance (NCQA), and internal clinical protocols.

Must comply fully and consistently with all company policies and procedures, with local and federal laws as well as with the regulations applicable to our Industry, to maintain appropriate business and employment practices. May carry out other duties and responsibilities as assigned, according to the requirements of education and experience contained in this document. MINIMUM QUALIFICATIONS: Education and Experience: Bachelor’s Degree in Nursing Science. At least three (3) years of experience in risk adjustment, coding, provider healthcare management, or clinical experience in a similar position in the Healthcare Insurance Industry is preferred.

“Proven experience may be replaced by previously established requirements. ”Certifications / Licenses: A valid Nurse & Association Nursing Professionals of Puerto Rico license and registration is required. A valid driver's license in the Commonwealth of Puerto Rico is required. Other: Car in good condition and available to travel to different locations in Puerto Rico. Knowledge of basic rules of medical record documentation and diagnosis validation is preferred. Knowledge of Healthcare Insurance regulatory compliance. Languages:

Spanish – Intermediate (comprehensive, writing and verbal)English – Intermediate (comprehensive, writing and verbal)“Somos un patrono con igualdad de oportunidad en el empleo y tomamos Acción Afirmativa para reclutar a Mujeres, Minorías, Veteranos Protegidos y Personas con Impedimento”