Clinical Reviewer (RN)
*This is a hybrid position
*This is a 6 month contract position
Description:
- The RN Clinical Reviewer will independently review/audit medical records associated with claims and work in a team environment on fraud, waste and abuse and program compliance issues for engagements with government healthcare programs, including primarily the Medicaid and Medicare programs.
Responsibilities:
- Utilizing healthcare knowledge and experience to review medical records for various types of medical services for accuracy, completeness and consistency with professional standards and compliance with billing and coding requirements
- Documenting and reporting findings of reviews and audits in accordance with professional standards and project protocols
- Participating in on-site field examinations and desk reviews of providers to audit clinical documentation
- Interpreting and analyzing health care data
- Working in a team environment to develop new audit recovery projects
- Working with state client personnel on health care reimbursement and compliance issues, including recommending changes and improvements of policies to ensure provider compliance
- Working collaboratively with the medical director and other clinical staff in the development and management of fraud, waste and abuse detection and other compliance projects
- Developing and maintaining general knowledge of reimbursement regulations, provider billing manuals and other Medicaid policies for claim payment compliance reviews and documentation to support current audit findings
- Maintaining security of and confidentiality of all protected health information (PHI)
- Participating in and contributing to quality management systems
- Additional responsibilities as assigned
Required Skills/Knowledge/Experience:
- Minimum three years of clinical documentation review experience, utilization management review experience, or health care claims auditing experience
- Knowledge and experience in detecting and investigating health insurance fraud, waste, and abuse
- Knowledge of healthcare coding principles to include ICD-9, ICD-10, CPT, HCPCS, RUGS, and DRG
- Experience and knowledge of state and federal healthcare regulations, including reimbursement and coverage policies
- Experience in quality improvement projects desired
- Proficient use of applicable software tools, including Microsoft Windows, Word, Excel, and Access
- Strong analytical and problem solving skills
- Excellent communication skills including written and verbal, including ability to present to large or small groups
- Self-directed and motivated, with ability to work independently under general instructions
- Ability to work in a team environment and manage multiple deadlines and prioritize assignments
- Well organized with a high degree of accuracy and attention to detail
- Must be able to travel based on client and business needs
- Not currently sanctioned or excluded from any program operated by federal or state agencies including Medicare and Medicaid
Education/Certifications:
- Bachelor’s degree in nursing required (Associate’s Degree from accredited nursing school with four or more years of additional clinical experience may be substituted in lieu of a bachelor’s degree)
- Current Registered Nurse (RN) license in good standing
- Certified Professional / Hospital Coder Certification/ Clinical Documentation Specialist Certification (CPC, CIC, COC, CPMA, CCS, CCS-P, RHIA, RHIT, CCDS, CDIP ) preferred or proof that certification will be obtained within twelve months
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