Position Purpose: The Clinical Reviewer will be responsible for conducting clinical reviews of medical records during the course of fraud investigations, special investigations, claims reviews and / or other program integrity initiatives such as requests for information in support of proactive data analysis efforts. In addition, this position applies Medicare and Medicaid criteria guidelines in making clinical determinations as to the appropriateness of payment coverage. In assuming this position, you will be a critical contributor towards our goal of improving healthcare delivery by identifying and eliminating fraud, waste and abuse. Responsibilities: Perform the clinical review in Standard Claims Processing System files (e.g., medical records, prior authorization, UB / HCFA forms, provider contracts, etc.) to determine accuracy of billing and identify abusive billing practices, potential FWA, or other scheme resulting in incorrect billing and payment Utilize CMS (LCD, NCD, etc.) and AHCA guidelines for coverage determinations and medical necessity in making clinical determinations as to the appropriateness of medical coverage Utilize extensive knowledge of medical terminology, ICD-9-CM, ICD-10-CM, HCPCS Level II and CPT coding along with analysis and processing of Medicare claims Coordinate and compile the written Investigative Summary Report upon completion of the records review Present cases not meeting criteria for medical necessity or level of care to Medical Directors Collaborate with physicians and other health professionals outside the Plan, as well as external regulatory agencies and law enforcement personnel Provide expert witness testimony as required Complies with the CMS Program Integrity Manual and Statement of Work guidelines Maintain chain of custody on all documents; follows confidentiality and security guidelines Works in collaboration with the Coding Analyst assigned to the Operations area, as well as the Manager of FWA and VP of Administration Meet performance goals established for the position Performs other duties and responsibilities as assigned by management that contribute to DHCP's goals and objectives and comply with the CMS Program Integrity Manual and Statement of Work guidelines and CMS directives and regulations Qualifications: 5 to 7 years of experience as a clinical reviewer and working with ICD-9/10 CM, CPTs, HCPCS, Diagnostic Related Groups (DRGs), Prospective Payment Systems and Correct Coding Initiative Experience in Medicare Advantage Plan, managed care or government contractor (e.g.: ZPIC, UPIC, RAC, MAC, etc.) Ability to read Medicare claims (both paper and electronic) with a basic knowledge of the Medicare claims system Advanced knowledge of medical terminology and experience in the analysis and processing of claims, utilization review, quality assurance procedures, payment methodologies and Part D – Pharmacy claims Strong analytical critical thinking skills Knowledge of Medicare operational and regulatory guidelines, as well as appl icable industry-based standards Excellent written and verbal communication skills with an ability to write professional summary reports Ability to manage priorities and execute tasks in a high-pressure environment Proficiency in MS Word, MS Excel, MS PowerPoint, and Internet Applications Graduate from an accredited school of nursing Preference given to BSN or higher prepared nurses with recent medical review experience in Medicare and/or Medicaid reviews Additional consideration given to Registered Nurses (RN) with an active license Note: This description indicates, in general terms, the type and level of work performed and responsibilities held by the team member(s). Duties described are not to be interpreted as being all-inclusive or specific to any individual team member. No Third Party Agencies or Submissions Will Be Accepted.
Our company is committed to creating a diverse environment. All qualified applicants will receive consideration for employment without regard to race, color, religion, gender, gender identity or expression, sexual orientation, national origin, genetics, disability, age, or veteran status. DFWP
Opportunities posted here do not create any implied or express employment contract between you and our company / our clients and can be changed at our discretion and / or the discretion of our clients. Any and all information may change without notice. We reserve the right to solely determine applicant suitability. By your submission you agree to all terms herein.
