Responsibilities: 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. 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.
Numbers & Facts
Location
Coral Gables, FL
Job Type
Full-time
Website
https://www.doctorshcp.com
Description
Position Purpose: The Clinical Reviewerserves as a subject matter expert in the clinical review of claims, claim disputes, appeals and FWA special investigations.
Responsibilities:
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:
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
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.