Job Description

Clinical Reviewer

The Clinical Reviewer serves as a subject matter expert in the clinical review of claims, claim disputes, appeals and FWA special investigations.

Responsibilities include:

• 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 include:

• 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. 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.

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