The Clinical Review Analyst supports population health and value-based care initiatives through comprehensive review and analysis of patient medical records, utilization, and healthcare cost information. This role evaluates high-risk, and recently hospitalized patients to identify drivers of hospital admissions, readmissions, and healthcare expenditures, as well as relevant clinical and risk factors.

DUTIES & RESPONSIBILITIES

• Review patient medical records, encounter documentation, hospital records, and other available clinical information to understand patient conditions, treatment history, and healthcare utilization.
• Analyze clinical information to identify key diagnoses, conditions, treatment patterns, and other factors contributing to healthcare utilization.
• Review additional clinical, utilization, and financial data as necessary to develop a comprehensive understanding of patient healthcare needs and utilization.
• Synthesize complex medical information into clear, concise summaries for use by clinical and operational teams.
• Maintain accurate and complete documentation of review findings in designated systems and tracking tools.
• Review medical records for patients recently discharged from an inpatient setting to understand the reason for admission, hospital course, discharge disposition, and relevant clinical factors.
• Identify factors potentially contributing to hospitalization, readmission risk, or ongoing healthcare utilization.
• Summarize hospitalization findings, relevant diagnoses, and other pertinent information in established tracking tools.
• Support multidisciplinary review of high-risk and recently hospitalized patients by providing accurate and timely clinical information.
• Participate in patient review meetings and provide relevant findings as requested.
• Perform medical record reviews for patients identified as high-risk or high-utilizing.
• Review available medical, pharmacy, claims, and financial information to identify factors contributing to healthcare expenditures.
• Evaluate utilization associated with Medicare Part A, Part B, and Part D services, as applicable, and summarize significant drivers of cost.
• Identify patterns of utilization and relevant clinical conditions that may contribute to elevated healthcare expenditures.
• Document findings in designated tracking tools and provide information needed to support clinical and operational review.
• Review clinical documentation for conditions that may represent potential HCC or other risk-adjustment opportunities.
• Identify potentially relevant diagnoses or clinical conditions for further evaluation by appropriate coding, risk adjustment, or clinical personnel.
• Escalate documentation or diagnosis questions to designated stakeholders when additional review is necessary.
• Support organizational risk-identification activities while maintaining appropriate separation between clinical review and formal coding validation responsibilities.
• Collaborate with clinical, population health, care management, risk adjustment, and operational teams to communicate review findings.
• Participate in meetings related to high-risk, high-risk, readmission, or patient utilization reviews.
• Maintain tracking spreadsheets, reports, and other documentation used to monitor patient review findings and trends.
• Assist with special analyses, projects, and reporting related to patient utilization, clinical risk, healthcare costs, and population health initiatives.
• Protect patient confidentiality and comply with HIPAA, organizational privacy, security, and confidentiality requirements.
• Perform other related duties and responsibilities as assigned.

EDUCATION AND PROFESSIONAL EXPERIENCE 

• Associate's or bachelor's degree in healthcare, health information management, nursing, public health, healthcare administration, or a related field preferred.
• Relevant clinical, healthcare operations, or medical record review experience may be considered in lieu of degree requirements, depending on organizational requirements.
• Experience reviewing medical records or clinical documentation in a healthcare setting.
• Experience working with electronic health records, preferably eClinicalWorks (eCW).
• Experience in population health, value-based care, utilization management, care management, risk adjustment, Medicare, or healthcare analytics preferred.
• Experience reviewing healthcare claims, utilization, or cost information preferred.
• Familiarity with HCCs and risk-adjustment concepts preferred.

PROFESSIONAL COMPETENCIES

• Ability to read, understand, and interpret medical records and common medical terminology.
• Understanding of healthcare utilization, including inpatient, outpatient, physician, and pharmacy services.
• General knowledge of Medicare Part A, Part B, and Part D services preferred.
• Working knowledge of HCC and risk-adjustment concepts preferred.
• Ability to analyze clinical and financial information and accurately summarize significant findings.
• Strong attention to detail and ability to identify relevant information within complex medical records.
• Strong organizational, time-management, and workload-prioritization skills.
• Ability to manage multiple patient reviews and meet established deadlines.
• Effective written and verbal communication skills.
• Ability to work collaboratively with clinical, operational, and cross-functional teams.
• Proficiency with Microsoft Excel, Word, Outlook, and Teams.
• Experience with eClinicalWorks or a comparable electronic health record system preferred.
• Knowledge of HIPAA requirements and patient confidentiality standards.