Clinical Review Supervisor

CERIS•Fort Worth, TX

1d•Remote

About The Position

The Diagnostic Related Groups (DRG) Clinical Supervisor is responsible for performing DRG validation (clinical/coding) reviews of medical records and/or other documentation to determine correct DRG/coding that is clinically supported as defined by review methodologies specific to the contract for which review services are being provided. This involves completing medical review forms, accurately documenting findings and non-findings and providing clinical/policy/regulatory support for the determination. This is a remote position.

Requirements

Clinical knowledge of medical necessity rules
Working knowledge of HIPAA Privacy and Security Rules
Ability to build strong working relationships both internally and externally
Strong attention to detail
Must possess problem solving, critical thinking skills
Minimal typing experience
Excellent written and verbal communication skills
Ability to think and work independently, while working in an overall team environment
Ability to work in a fast paced/production environment
Proficient in Microsoft Office applications
N./L.V.N. preferred
CCS or CIC required with DRG auditing experience in ICD-10-CM, ICD-10 PCS
Proficient in Medicare, CMS guidelines and ICD-10 coding guidelines
Minimum of 3-5 years of inpatient/DRG auditing experience in a hospital setting and/or payer setting
A minimum of 2 years of supervisory experience dealing with clinical auditors is required
Experience with claims denials and appeals required

Responsibilities

Supervises all daily activities of the DRG Clinical Auditors
Demonstrated knowledge of, ICD-10-CM and PCS codes, and DRG coding, understanding of payer rules and regulations, including Medicare and Medicaid with the ability to work independently with minimal supervision and demonstrate initiative
Completes DRG audits as needed
Responsible for the overall integrity of the quality of diagnosis and procedure codes verified by the clinical review nurses, for inpatient records and documentation received with the accompanied claim
Responsible for holding the DRG Clinical Auditors to the quota and error/accuracy rate
Assists with team coverage and provide support when needed
May be required to travel overnight and attend meetings or training
Additional duties as assigned