Complex Claims Clinical Reviewer

May 16

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Logo of Vaya Health

Vaya Health

Vaya Health is a North Carolina-based organization that manages services for individuals with behavioral health issues, including mental health and substance use disorders, intellectual and developmental disabilities (I/DD), and traumatic brain injuries (TBI). The organization provides Medicaid services tailored for these populations, focusing on a person-centered approach that connects members to the necessary care and support for their unique health and wellness goals. Vaya Health emphasizes collaboration across various care areas to ensure comprehensive support for its members, fostering healthier communities across the region.

Health Technology • Managed Care • Healthcare • Mental Illness • Substance Use Disorders

501 - 1000 employees

Founded 1972

⚕️ Healthcare Insurance

🌍 Social Impact

📋 Description

• LOCATION: Remote -- This is a home based, virtual position that operates Monday – Friday from 8:30am-5:00pm (EST). • GENERAL STATEMENT OF JOB The Complex Claims Clinical Reviewer will conduct prepayment and post-payment audits of DRG coding and clinical documentation. • The ideal candidate will have an extensive background in inpatient coding and has a comprehensive understanding of reimbursement guidelines, particularly the DRG payment systems. • This position is responsible for auditing inpatient medical records and generating high-quality recoverable claims by reviewing medical records and other documentation to evaluate the accuracy of coding and DRG assignment. • ESSENTIAL JOB FUNCTIONS The role involves conducting prepayment and post-payment reviews of inpatient hospital claims, validating the appropriateness of billed ICD-10-CM and ICD-10 PCS codes and MS-DRGs. • Utilizing evidence-based criteria supported by current clinical research, the Complex Claims Clinical Reviewer applies clinical expertise and judgment to ensure compliance with medical policy, medical necessity guidelines, and accepted standards of care. • Responsibilities include generating Decision Action Notices that provide clear and concise rationales referencing clinical evidence, initiating and verifying claim adjustments, maintaining audit documentation, and preparing statistical data. • The reviewer must have a thorough knowledge of federal and state guidelines and regulations related to coding and billing practices, as well as strong oral and written communication skills. • Additionally, the role involves identifying, monitoring, and analyzing aberrant patterns of utilization or fraudulent activities by healthcare providers through prepayment claims review, post-payment auditing, and provider record review. • Administrative Activities: The Complex Claims Clinical Reviewer participates in both informal and formal appeal processes, defending decisions before Vaya reconsideration panels, hearing officers, and administrative law judges, and providing litigation testimony as applicable. • The role involves working in conjunction with various regulatory bodies to ensure compliance and effectiveness in addressing fraud prevention. • Additionally, the Complex Claims Clinical Reviewer proposes new fraud prevention edits for the automated claims and billing system when new fraudulent schemes are identified. • Support Activities: Perform other duties as assigned, including technical assistance and provider education based upon need, area of expertise, special interests, and availability of resources.

🎯 Requirements

• Adherence to official coding guidelines, coding clinic determinations, and CMS and other regulatory compliance guidelines and mandates. • Expert knowledge of DRG & ICD-10 coding required. • Strong working knowledge of applicable industry-based standards. • Proficiency in Word, Access, Excel, and other applications. • Excellent written and verbal communication skills. • Medicaid experience is a plus.

🏖️ Benefits

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