The
Medical Review Audit Supervisor - Clinical leverages their nursing background, deep knowledge of clinical review, and experience leading others to manage staff and operational results for a remote team of nurses and other audit roles, performing clinical review audits. The Supervisor will leverage first-hand experience and knowledge of claims auditing for supporting management with strategy activities such as needs assessments, capacity planning, and ensuring required staffing levels and productivity & quality standards are being achieved consistently.
Key Responsibilities to include:- Regularly performs limited volume of clinical audits to maintain subject matter expertise, and additionally as needed to support business needs.
- Performs audit quality assurance reviews to supplement QA team activity as necessary based upon business need or special projects.
- Contributes to the resolution of quality review rebuttals.
- May perform appeals review/activity to supplement Appeals team, based upon business need.
- Actively identifies and recommends opportunities for cost savings and improving outcomes that can have a direct impact to the company's profitability.
- Effectively ensures adherence to medical review guidelines and training requirements of staff.
- Supports audit management and segment specialists with activities for new concept implementation
- Supports management with needs assessments and capacity planning
- Monitor and manage inventory of assigned business to ensure timelines are met.
- Use data, reports and experience to proactively identify potential backlogs and align resources to meet business needs and SLAs.
- Oversee and review audit determinations to ensure consistency in decision-making.
- Collaborate with other departments to resolve operational problems.
- Proactively monitors and in alignment with applicable management ensures activity required to meet team staffing levels necessary to achieve business objectives.
- Provides support as needed to ensure auditors are equipped with tools and resources required to perform audits.
- Supervise daily activities of clinical audit staff that may include both salaried exempt and hourly employees.
- Provide audit guidance to medical review staff; identify trends and present solutions.
- Routinely provides production and quality performance-based progress reports, coaching, and constructive feedback to staff.
- Manages team Time and Attendance (time off/use of accruals, attendance, attendance points and timecards for hourly staff, etc.) in accordance with applicable policies and procedures.
- Collaborates with The People Team for applicable corrective action as applicable.
- Complete and conduct performance reviews for assigned staff.
- Conduct team meetings with direct reports on a regular basis.
- Provide leadership to team members, provide solutions, and resolve conflicts.
- Escalate to management and collaborate with HR as applicable to bring appropriate solutions to employee matters.
- Provide reporting and updates to management as required and appropriate for operational and staff activity and results.
- Participates in and contributes to applicable department meetings.
- May participate to client-facing meetings; research and analyze issues; present findings and solutions; and/or provider training.
- May support management with activities to monitor inventory and activity of 3rd party/subcontractors.
- Become subject matter expert for assigned business segment(s).
- Maintain current knowledge and changes that affect our industry and clients as it pertains to medical practice, technology, regulations, legislation and business trends.
- May support training material/tools and best practices development.
- Identify needs and ensure team receives necessary training.
- Support training activities for new audit staff or provide supplemental training for existing staff as needed.
- Contributes to positive team environment that fosters open communication, sharing of information, continuous improvement, and optimized business results.
- Receives feedback and adjusts work priority for self and team as necessary.
- Leads by example and conducts work in accordance with company policies, government regulations and law.
- Perform other incidental and related duties as required and assigned to meet business needs.
Knowledge, Skills and Abilities Needed:- Strong knowledge of medical documentation requirements and an understanding CMS, Medicaid and/or Commercial insurance programs, particularly the coverage and payment rules.
- Experience with CPT/HCPCs/ICD-9/ICD-10/MS-DRG coding.
- Proficiency with MCS 1500/UB 04 forms
- Working knowledge of encoder
- Experience with utilization management systems or clinical decision-making tools such as Medical Coverage Guidelines, Milliman or InterQual.
- Proven ability to review, analyze, and research medical billing, documentation, and coding issues
- Reimbursement policy and/or claims software analyst experience
- Familiarity with interpreting electronic medical records (EHR)
- Willing and able to lead by example, communicate ideas, take initiative and drive the team to achieve organizational goals.
- Experience in developing, documenting and implementing process and procedures.
- Experience in inventory management, resource planning and report generation.
- Skill in analyzing information, identifying trends and presenting solutions.
- Understands inventory management objectives, activities, and key drivers in achieving operational goals.
- Demonstrated ability to consistently apply sound judgment and good effective decision making.
- Excellent communication skills, both verbal and written; ability to communicate effectively and professionally at all levels within the organization, both internal external.
- Demonstrated ability to collaborate effectively in a variety of settings and topics.
- Excellent editing and proofreading skills.
- Demonstrated ability to successfully develop, lead, and motivate a team to high performance; effectively provides constructive feedback and coaching for successful outcomes.
- Ability to independently organization, prioritize and plan work activities effectively for self and others; develops realistic action plans with the ability to multi-task effectively.
- Excellent time management and delivers results balancing multiple priorities.
- Strong analytical skills; synthesizes complex or diverse information; collects and researches data; uses experience to compliment data.
- Leverages strong critical thinking, questioning, and listening skills to research and effectively resolve complex issues.
- Demonstrated ability to identify areas of opportunity and create efficiencies in workflows and procedures.
- Demonstrated ability to be proactive; identifies and resolves problems in a timely manner; develops alternative solutions.
- Ability to create documentation outlining findings and/or documenting suggestions.
- Strong general technical skills, including, but not limited to Desktop and MS Office applications (Intermediate Excel Skills), application reporting tools, and case management system/tools to review and document findings.
- Solid technical aptitude with demonstrated ability to quickly learn and adapt to new systems and tools.
- Ability to be flexible and thrive in a high pace environment with changing priorities.
- Adaptable to applying skills to diverse operational activities to support business needs.
- Self-starter with the ability to work independently in remote setting with minimum supervision and direction in the form of objectives.
- Serves as positive role model, and demonstrates characteristics that align and contribute to a collaborative culture of continuous improvement and high performing teams.
Required and Preferred Qualifications:- Current active unrestricted Nursing license in good standing required. Not currently sanctioned or excluded from the Medicare program by OIG, is also required.
- Medical coding certification is a plus.
- 3+ years diverse nursing experience providing direct care in an inpatient or outpatient setting.
- 2+ years of performing medical record audits in a provider setting, or in a payer setting for a health insurance company.
- 5+ years in health care claims that demonstrates expertise in ICD-9/ICD-10 coding, HCPS/CPT coding, DRG and medical billing experience for an Insurance Company or hospital required. Those who have less than 5 years experience may be considered based upon demonstrated skills and/or formal training and other relevant experiences
- 3+ years relevant supervisory or leadership experience in similar business environment, preferred. Experience managing remote staff is a plus.
- Some Supervisory experience may be required for certain Supervisor roles.
- Prior experience in payer edit development, and/or reimbursement policy experience a plus.
EXPECTED ANNUAL SALARY RANGE: $85,000 - 110,000
