SUMMARY STATEMENT
The Lead Clinical Review Nurse serves as the subject matter expert (SME) to peers, external and internal customers in relation to review decisions and inquiries. This includes the review of Medicare Part A and/or B claims suspended for prepayment review, providers under review and unusual or complex cases requiring a higher level of review on a pre and post payment basis, as well as those under appeal.

ESSENTIAL RESPONSIBILITIES
To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. This list of essential job functions is not exhaustive and may be supplemented as necessary.

90% of time will be spent on one or more of the following activities depending on assignments:
* Lead and coordinate the Medical Review (MR)/Clinical Appeal activities in accordance with organizational strategies and program requirements, to include:
o Validation of edits and/or audits which produce workload and adjudication of claims suspended for review.
o Trending of appeals data to monitor and evaluate decision accuracy and consistency of medical decision making and identification of the need for staff education.
o Assuring the accurate, efficient and timely payment determinations for both medical review and program management claim reviews. This includes reviews of Medicare Part A and/or B claims suspended for prepayment review, providers under review and unusual or complex cases requiring a higher level of review on a pre and post payment basis as well as appealed cases.
o Assuring that prepayment and post payment review activity conducted by the team members is implemented and completed in a manner consistent with program requirements and that medical reviews are completed exercising sound medical knowledge and within CMS guidelines.
o Motivating, encouraging and leading a diversely trained professional team.
o Analytical and complex problem resolution within a dynamic business environment and significant budget constraints.
o Coordinating between Program Management, Program Integrity and Clinical Appeals to aid in facilitating consistent medical decision accuracy.
* Serve as technical expert of the claims processing system, claims payment policies and procedures, Medicare regulations and CMS requirements:
o Design procedures and protocols to direct clinical and other resources in analyzing data to determine the need for clinical review activities.
o Recommend process improvements designed to improve accuracy, timeliness of processing and/or eliminate manual effort.
o Analyze and interpret requirements of the Social Security Act, code of Federal Regulations, and other program requirements.
* Advise internal and external professional clinical personnel and make decisions related to maximizing the performance of the department in line with organizational strategy and the current trending appeal receipts:
o Work with Informatics and other workgroups to obtain relevant statistical analysis that can aid in the identification of potential abuse situations, and variations in appeals workload.
o Participate in the review of data findings and assist management in determining the appropriate level of progressive corrective action in line with CMS requirements.
o Coordinate timely and accurate responses for all providers under review including inquiries directly from providers, attorneys, congressional staff, CMS, etc. as they relate to audit activities.
o Identify quality-related opportunities and notify management when it appears that quality is being compromised.

The remaining 10% of time will be spent on the following activities depending on assignments:
* Contribute to educational interventions related to review activities based on trends/patterns identified (e.g. refresher training, performance mentoring)

Performs other duties as the supervisor may, from time to time, deem necessary.

REQUIRED QUALIFICATIONS
* High School diploma or GED
* 3 years' related work experience with a minimum of 2 years' clinical experience
* Excellent verbal and communication skills
* Leadership skills
* Demonstrated experience with analyzing and resolving complex problems and implementing changes effectively
* Medicare Part A or B clinical review experience
* Strong computer skills to include Microsoft office proficiency
* Data analysis skills and experience

CERTIFICATIONS, LICENSES, REGISTRATIONS
* Valid unrestricted Registered Nurse (RN) License

PREFERRED QUALIFICATIONS
Education:
* Bachelor of Science in Nursing (BSN)

Work Experience
* 5 or more years of experience in the clinical review setting of the insurance industry
* Experience using claims processing system (e.g., MCS/FISS), etc.
* Medicare Part A and B appeals processing or Medical Review experience.

CERTIFICATIONS, LICENSES, REGISTRATIONS
* Certified Professional Coder/Certified Professional Utilization Reviewer

This opportunity is open to remote work in the following approved states: AL, AR, FL, GA, ID, IN, IO, KS, LA, MS, NE, NC, ND, OH, PA, SC, TN, TX, UT, WV, WI, WY. Specific counties and cities within these states may require further approval. In FL and PA in-office and hybrid work may also be available.