Job Description

Job Description

Job Description

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

• 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

• 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

• 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)

No Third Party Agencies or Submissions Will Be Accepted.

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