Clinical Reviewer

Doctors Healthcare Plans•Coral Gables, FL

About The Position

The Clinical Reviewer serves as a subject matter expert in the clinical review of claims, claim disputes, appeals, and fraud, waste, and abuse (FWA) special investigations. The role evaluates facility claims and supporting documentation to determine medical necessity and coverage, researches potential FWA, and prepares investigative reports. The Clinical Reviewer collaborates with Medical Directors and other departments, maintains accurate documentation and HIPAA confidentiality, and meets established performance goals.

Requirements

At least 5–7 years of experience as a clinical reviewer of facility claims in a Medicare Advantage environment, managed healthcare, or as a government contractor.
Knowledge of Medicare Advantage, CMS, and AHCA regulatory requirements and applicable industry standards.
Clinical experience in an acute care setting.
Comprehensive understanding of the claim review process, including clinical record review, and broad knowledge of applicable processes, procedures, and billing guidelines.
Proven experience analyzing clinical records, claim and FWA audits, utilization review, and quality assurance.
Advanced knowledge of clinical terminology and standards, including MCG guidelines, LCDs/NCDs, ICD-9/10, DRGs, OPPS, CPTs, HCPCS, the Correct Coding Initiative, and the Final Rule.
Outstanding investigative and research skills.
Ability to thrive in a complex, high-pressure environment.
Strong analytical and critical-thinking competencies.
Excellent written and verbal communication skills.
High degree of computer literacy and advanced Excel spreadsheet skills for operational data analysis and reporting.
Bachelor’s degree in Nursing or equivalent.
Active and unrestricted RN or LPN license or equivalent.

Nice To Haves

Coding certification preferred, such as RHIA, RHIT, an inpatient coding credential (CCS/CIC), CCDS, or CPC.

Responsibilities

Review facility claim disputes, including clinical records, itemized bills, prior authorizations, concurrent review, coding guidelines, and provider compensation, to determine medical necessity and coverage.
Use MCG guidelines, LCD/NCDs, and CMS guidelines to make clinical determinations.
Present reviewed cases to the Medical Director.
Resolve prior authorization issues arising from developed claims.
Use internal systems, external platforms, and applicable state and federal guidelines to research potential FWA.
Write FWA Investigative Summary Reports for Special Investigations and support findings and recommendations.
Comply with the CMS Program Integrity Manual and Statement of Work guidelines.
Maintain appropriate documentation for claim reviews in accordance with departmental guidelines and procedures.
Protect HIPAA confidentiality and privacy when completing assigned work.
Collaborate with other departments to integrate best practices and improve medical management processes.
Meet performance goals established for the position.
Perform additional duties and responsibilities as assigned by management.