Program Integrity Clinical Reviewer II

CareSource•Dayton, OH

4d•$72,200 - $115,500•Onsite

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.

Requirements

Bachelor of Science Degree equivalent experience years of relevant experience is required
Minimum of five (5) years clinical practice experience required
Significant experience auditing medical records against claims is required
CPT, HCPCS and ICD-10 coding knowledge is required
Proficient with Microsoft Office Word, Excel and PowerPoint
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 is required
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 preferred
Medical research experience is preferred
Knowledge of Medicare/Medicaid/Managed Care preferred
Medical research background preferred

Responsibilities

Conduct claim reviews against medical records to determine claim accuracy for claims payment. This will support prepayment, post-payment, and SIU teams.
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