Program Integrity Clinical Reviewer II
About The Position
The Program Integrity Clinical Reviewer II contributes to the investigative process by evaluating medical records, looking for correct documentation, trends, patterns, missing information, upcoding, unbundling, etc. in relation to clinical documentation, medical standards, and CPT, HCPCS and ICD-10 codes. This role supports prepayment, post-payment, and SIU teams by conducting claim reviews against medical records to determine claim accuracy for claims payment. The reviewer will also conduct meetings to present identified clinical issues and associated research to Medical Directors and physician experts for validation. Additionally, this role will conduct, participate in, or contribute to on-site audits and investigations of medical professionals, subcontractors, and contracted entities, and assist audit and investigative teams in developing clinical and coding-based audit tools. The position involves drafting proposed provider education and formal corrective action plans for clinical and coding deficiencies, and providing SIU perspective to the development of clinical and payment policies and the Utilization Management Committee. Collaboration with other departments such as Pharmacy, Medical Management, Provider Relations, Claims, Contracting, Case Management, and Legal is essential. The role is responsible for maintaining the confidentiality of all sensitive investigative information and for developing and maintaining SIU-specific clinical and investigative training materials, including processes (SOPs). The reviewer will create and execute monthly audits of investigative staff’s work to ensure processes are followed and to identify additional training opportunities, utilizing and providing multiple training mediums like presentations, quick reference tools, speakers, internet, and state and federal resources. Any other job-related instructions as requested will also be performed.
Requirements
- Bachelor of Science Degree or equivalent experience.
- Minimum of five (5) years clinical practice experience.
- Significant experience auditing medical records against claims.
- CPT, HCPCS and ICD-10 coding knowledge.
- Proficient with Microsoft Office Word, Excel and PowerPoint.
- Strong organizational and time management skills.
- Broad-based clinical and medical coding knowledge.
- Strong analytical skills with high attention to details.
- Skill in negotiating issues and resolving problems.
- High-level Investigative experience.
- Training/teaching experience and demonstrated knowledge of adult learning environment.
- Excellent written and verbal communication skills with adeptness to create, present and evaluate present department, role-focused teaching materials across topics.
- Ability to communicate verbally and in written form with a variety of levels within the organization.
- Critical decision making/problem solving skills.
- Considerable skill set in planning and project management.
- Ability to work independently and within a team environment.
- Current, unrestricted RN licensure in state of practice.
- Certified Medical Coder (CPC, RHIT or RHIA) is required at time of hire or within 18 months of hire date.
Nice To Haves
- Prior Fraud, Waste, Abuse (FWA) investigation and auditing experience.
- Medical research experience.
- Knowledge of Medicare/Medicaid/Managed Care.
- Medical research background.
Responsibilities
- Conduct claim reviews against medical records to determine claim accuracy for claims payment.
- Conduct meetings to present identified clinical issues and associated research to Medical Directors and physician experts for validation.
- Conduct, participate or contribute to on-site audits and investigations of medical professionals, subcontractors and contracted entities.
- Assist the audit and investigative teams in the development of clinical and coding based audit tools.
- Draft proposed provider education and formal corrective action plans for clinical and coding deficiencies.
- Provide SIU perspective to the development of clinical and payment policies and the Utilization Management Committee.
- Collaborate with other departments including, but not limited to Pharmacy, Medical Management, Provider Relations, Claims, Contracting, Case Management, and Legal.
- Responsible for maintaining confidentiality of all sensitive investigative information.
- Develop and maintain SIU specific clinical and investigative training materials to include processes (SOPs).
- Create and execute monthly audits of investigative staff’s work to ensure processes are followed and to identify additional training opportunities.
- Create, use and/or provide multiple training mediums such as presentations, quick reference tools, speakers, internet and state and federal resources, etc.
- Perform any other job related instructions as requested.
Benefits
- In addition to base compensation, you may qualify for a bonus tied to company and individual performance.
- We are highly invested in every employee’s total well-being and offer a substantial and comprehensive total rewards package.
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What This Job Offers
Job Type
Full-time
Career Level
Mid Level
