Position Purpose: The
Clinical Reviewer serves as a subject matter expert in the clinical review of claims, claim disputes, appeals and FWA special investigations.
Responsibilities:- Review of facility claim disputes including clinical records, itemized bills, prior authorizations, concurrent review, coding guidelines and provider compensation to determine appropriateness of medical necessity and coverage
- Reference MCG guidelines, LCD/NCD's and CMS guidelines to make clinical determinations
- Present reviewed cases to Medical Director
- Resolve prior authorization issues derived from developed claims
- Utilize internal system, external platforms and appropriate state and federal guidelines to research potential FWA
- Write FWA Investigative Summary Report for Special Investigations, and provide support for findings and recommendations
- Comply with the CMS Program Integrity Manual and Statement of Work guidelines
- Maintains appropriate documentation on all claim reviews according to departmental guidelines and procedures
- Understand and maintain HIPAA confidentiality and privacy standards when completing assigned work
- Collaborate with other departments to integrate best practices and enhance overall medical management processes
- Meet performance goals established for the position
- Performs additional duties and responsibilities as assigned by management
Qualifications:- Minimum 5-7 years of experience as a clinical reviewer of facility claims in a Medicare Advantage environment, managed healthcare or government contractor
- Knowledge of Medicare Advantage, CMS and AHCA regulatory requirements, as well as applicable industry-based standards
- Clinical experience within an acute care setting
- Comprehensive understanding of the claim review process including clinical record review, and a broad knowledge of applicable processes, procedures and billing guidelines.
- Proven track record in the analysis of clinical records, claim and FWA audits, utilization review and quality assurance
- Advanced knowledge of clinical terminology such as MCG guidelines, LCD's/NCD's, ICD-9/10, DRG's, OPPS, CPTs, HCPCS, Correct Coding Initiative and Final Rule
- Outstanding investigative and research skills
- Able 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 spreadsheets for operational data analysis and reporting
Education:- Bachelor's degree in Nursing or equivalent
- Active and unrestricted RN or LPN license or equivalent
- Coding Certification preferred (RHIA, RHIT, Inpatient Coding Credential - CCS/CIC, CCDS or CPC)
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.
