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Shahyan Currimbhoy

Posted on November 02, 2022 | 3 min read

The Opportunity and Benefits of the Clinical Review Specialist


Operational Excellence

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Clinical Review Specialist in Risk Adjustment

A hallmark (and problem) of technology in healthcare has been the drive to automate processes and eliminate staff headcount to boost ROI. For risk adjustment operations in particular, this often results in an increased burden on physicians, asking them to learn and apply CPT, ICD-10, HCC, and any number of other codes alongside their primary duty: providing excellent care. As Edifecs’ provider solutions continue to develop, preserving coding expertise and allowing physicians to focus on care is of utmost priority. Much like our payer solution, Edifecs Retro Review, our goal is to empower experts and provide a strong, quantifiable ROI through NLP-supported applications. The clinical review specialist (CRS), a role that our early Pre-Visit Prep adopters have utilized to great effect, continues the trend of Edifecs focusing on providing the best tools for your talent.

As a refresh, NLP suspecting in Edifecs Pre-Visit Prep is a forward-looking, prospective view of conditions and treatments to identify diagnosis gaps (“suspects”) and bring them forward for review in upcoming appointments. Our NLP engine evaluates all available clinical evidence for a given patient looking for MEAT or TAMPER, protocols for evaluation under risk adjustment that show prior clinical evaluation for a condition not documented or recently reconfirmed. For example, if there’s a prior claim for type-2 diabetes but no code for a given year, our system suspects type-2 diabetes and notifies the provider to reconfirm for the year, both checking on the patient’s health status and ensuring proper risk score capture. More subtly, our solution can also recognize a note corresponding to COPD and a durable medical equipment claim for oxygen, but no coded COPD diagnosis and provide that as a suspected condition for review.

These are overt examples but the point of the tool is ultimately to ensure members of the team are empowered to operate at top of their expertise and make full use of medical data previously impossible to properly leverage. This is where the clinical review specialist shines.

Because Pre-Visit Prep is, in many ways, a very deep chart prep, the CRS role has been developed for implementation of pre-encounter risk workflows. It combines the technical skill set of coders and clinical documentation expertise of care team members like RNs, care managers, medical assistants, and CDI specialists. In doing so, the CRS can dedicate themselves to the evaluation suspected risk adjustable conditions and their evidence for the final review by a CMS-designated provider (PA, MD, DO, APP, etc.).  Because the CRS can apply clinical knowledge to properly evaluate NLP suspects of undocumented diagnoses by way of the associated evidence, the CRS exists at the nexus between coding and clinical activity. Through this, they support an informed, team-centered approach that helps value-based care flourish for doctors and patients alike.

Through those skills, clinical review specialists are the first set of eyes curating NLP derived clinical suspects. They’re a partner with the practice providers, reducing the review burden rather than increasing it, allowing the full breadth of a pre-encounter risk workflow to impact care and the financial health of an organization that has adopted risk. In this way, Edifecs continues its legacy of providing outcomes by offering greater reach for already cultivated expertise, empowering teams rather than reducing their headcount and increasing physician burden.

To learn more about Pre-Visit Prep, check out this video.

You can also always contact us to discuss this, or any of our solutions.


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