Program Integrity Clinical Reviewer II

Job not on LinkedIn

🔥 7 minutes ago

🇺🇸 United States – Remote

💵 $72.2k - $115.5k / year

⏰ Full Time

🟡 Mid-level

🟠 Senior

🔍🏥 Medical Reviewer

🦅 H1B Visa Sponsor

This company has sponsored H1B visas in the past.

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CareSource

WebsiteLinkedInAll Job Openings

1001 - 5000 employees

Founded 30+ years

🏥 Healthcare

🛡️ Insurance

⚕️ Healthcare Insurance

Healthcare • Insurance • Healthcare Insurance

CareSource is a health services company focused on providing affordable health insurance and healthcare solutions. It offers a wide range of plans including Medicaid, Marketplace, and Medicare Advantage, targeting low-income adults, families, children, pregnant women, elderly adults, and people with disabilities. Additionally, CareSource provides members with resources for COVID-19 support, dental, vision, and hearing benefits, as well as pharmacy services. The company emphasizes easy access to healthcare management through online platforms and a mobile app.

📋 Description

• Evaluate medical records for correct documentation, trends, patterns, missing information, upcoding, unbundling, and compliance with clinical documentation, medical standards, and CPT, HCPCS, and ICD-10 codes • Conduct claim reviews against medical records to determine claim accuracy for payment, supporting prepayment, post-payment, and SIU teams • Present identified clinical issues and research to Medical Directors and physician experts for validation • Conduct, participate in, or contribute to on-site audits and investigations of medical professionals, subcontractors, and contracted entities • Assist audit and investigative teams in developing clinical and coding-based audit tools • Draft proposed provider education and formal corrective action plans for clinical and coding deficiencies • Provide SIU perspective to clinical and payment policies and the Utilization Management Committee • Collaborate with Pharmacy, Medical Management, Provider Relations, Claims, Contracting, Case Management, Legal, and other departments • Maintain confidentiality of sensitive investigative information • Develop and maintain SIU-specific clinical and investigative training materials and SOPs • Create and execute monthly audits of investigative staff work to ensure processes are followed and identify training opportunities • Create, use, and provide training mediums including presentations, quick reference tools, speakers, internet, and state and federal resources • Perform other job-related instructions as requested

🎯 Requirements

• Bachelor of Science degree or equivalent experience years of relevant experience is required • Minimum of five (5) years clinical practice experience required • Significant experience auditing medical records against claims required • Prior Fraud, Waste, Abuse (FWA) investigation and auditing experience preferred • Medical research experience preferred • CPT, HCPCS and ICD-10 coding knowledge required • Knowledge of Medicare/Medicaid/Managed Care preferred • Proficient with Microsoft Office Word, Excel and PowerPoint • 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 department and role-focused teaching materials • 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 • Current, unrestricted RN licensure in state of practice required • Certified Medical Coder (CPC, RHIT or RHIA) required at time of hire or within 18 months of hire date

🏖️ Benefits

• Bonus tied to company and individual performance may be available • Comprehensive total rewards package • Equal Opportunity Employer environment focused on belonging and support for individuals of all backgrounds