Program Integrity Clinical Reviewer II (Readmission experience preferred)

Job Summary:

The Program Integrity Clinical Reviewer II contributes to the investigative process by evaluating medical records, looking for correct documentation, trends, patterns, missing information, upcoding, unbundling, etc. in relation to clinical documentation, medical standards, and CPT, HCPCS and ICD-10 codes, with an emphasis on readmission.

Essential Functions:

• Conduct claim reviews against medical records to determine claim accuracy for claims payment.  This will support prepayment, post-payment, and SIU teams.
• Conduct meetings to present identified clinical issues and associated research to Medical Directors and physician experts for validation
• Conduct, participate or contribute to on-site audits and investigations of medical professionals, subcontractors and contracted entities
• Assist the audit and investigative teams in the development of clinical and coding based audit tools
• Draft  proposed provider education and formal corrective action plans for clinical and coding deficiencies
• Provide SIU perspective to the development of clinical and payment policies and the Utilization Management Committee
• Collaborate with other departments including, but not limited to Pharmacy, Medical Management, Provider Relations, Claims, Contracting, Case Management, and Legal
• Responsible for maintaining confidentiality of all sensitive investigative information
• Develop and maintain SIU specific clinical and investigative training materials to include processes (SOPs)
• Create and execute monthly audits of investigative staff’s work to ensure processes are followed and to identify additional training opportunities
• Create, use and/or provide multiple training mediums such as presentations, quick reference tools, speakers, internet and state and federal resources, etc.
• Perform any other job related instructions as requested

Education and Experience:

• Bachelor of Science Degree equivalent experience years of relevant experience is required
• Minimum of five (5) years clinical practice experience required
• Significant experience auditing medical records against claims is required
• Prior Fraud, Waste, Abuse (FWA) investigation and auditing experience preferred
• Medical research experience is preferred

Competencies, Knowledge and Skills:

• CPT, HCPCS and ICD-10 coding knowledge is required
• Knowledge of Medicare/Medicaid/Managed Care preferred
• Proficient with Microsoft Office  Word, Excel and PowerPoint
• Strong organizational and time management skills
• Broad-based clinical and medical coding knowledge
• Strong analytical skills with high attention to details
• Skill in negotiating issues and resolving problems
• High-level Investigative experience
• Training/teaching experience and demonstrated knowledge of adult learning environment
• Excellent written and verbal communication skills  with adeptness to create, present and evaluate present department, role-focused teaching materials across  topics
• Ability to communicate verbally and in written form with a variety of levels within the organization
• Critical decision making/problem solving skills
• Considerable skill set in planning and project management
• Ability to work independently and within a team environment
• Medical research background preferred

Licensure and Certification:

• Current, unrestricted RN licensure in state of practice is required
• Certified Medical Coder (CPC, RHIT or RHIA) is required at time of hire or within 18 months of hire date

Working Conditions:

• General office environment; may be required to sit or stand for extended periods of time

Compensation Range:

CareSource takes into consideration a combination of a candidate’s education, training, and experience as well as the position’s scope and complexity, the discretion and latitude required for the role, and other external and internal data when establishing a salary level. In addition to base compensation, you may qualify for a bonus tied to company and individual performance. We are highly invested in every employee’s total well-being and offer a substantial and comprehensive total rewards package.

Compensation Type (hourly/salary):

Organization Level Competencies

• Fostering a Collaborative Workplace Culture

• Cultivate Partnerships

• Develop Self and Others

• Drive Execution

• Influence Others

• Pursue Personal Excellence

• Understand the Business