Clinical Consultant I

This is a fully remote position, open to applicants in United States.

📋 Description

• Assist Clinical Services teams in verifying the quality and consistency of processes on the CPE editing engine.

• Offer subject matter expertise in Coding Validation to clients and internal stakeholders during planning, implementation, go-live, transition to operations, and throughout the contract period.

• Serve as a bridge for clinical information between internal partners and external clients.

• Aid clients in understanding Coding Validation policies and concepts.

• Address client inquiries in accordance with established policies and procedures.

• Examine and analyze client inquiries related to Coding Validation and Change Requests.

• Evaluate the impact of decisions on relevant policies and communicate with clients to clarify information.

• Provide resources for provider abrasion issues and ensure the quality of Coding Validation.

• Articulate Coding Validation concepts both in writing and verbally.

• Relay quality review findings and necessary revisions to clients.

• Collaborate with the Quality Team to create action plans that address and mitigate future issues.

• Work alongside Client Teams to cultivate and maintain client relationships.

• Offer client-focused feedback on edit configuration changes, rule updates, and new editing development.

• Assist Clinical Content Teams by providing client-perspective feedback on trends and new rules.

• Collaborate with Quality, Training, and Operations Teams on updates to review guidelines, client-specific changes, and issues.

• Support Coding Validation implementations, including reviewing test claims and internal go-live support.

• Act as a liaison for support during the appeals management process.

• Contribute to CPE Clinical Services quality assurance, which includes pre- and post-release testing.

• Assist in the validation and review of client payment policies.

• Maintain Client Information Workbooks.

• Provide assistance during user acceptance testing in Nucleus.

⛳️ Requirements

• Associate or Bachelor’s degree in Nursing.

• Active and unrestricted Registered Nursing license (RN) in the state of residence.

• Professional coder certification (CPC, CPC-H, CPC-P, or CCS-P), RHIT, or RHIA certification is mandatory.

• A minimum of 2 years of clinical experience as a Registered Nurse.

• At least 1 year of experience in Coding Validation.

• A minimum of 1 year of coding experience in both professional and outpatient facilities.

• At least 1 year of experience in claims adjudication, medical/payment policy, or utilization review for a managed care or healthcare insurance company, or related experience.

• A minimum of 1 year of experience in customer service or client management, with a strong emphasis on the healthcare setting.

• Capability to analyze complex data and distill it for both customer and internal understanding.

• Strong research skills and familiarity with CMS guidelines, regulatory compliance guidelines, and medical payment policies.

• Proficient in Microsoft Office Suite (Word, Excel, PowerPoint).

• Preferred knowledge of Cotiviti systems.

• Must demonstrate basic working knowledge of Nucleus, JIRA, Mantis, MicroStrategy, and Tableau within 90 days of hire.

• Understanding of medical terminology.

• Effective analytical and problem-solving abilities.

• Ability to manage multiple tasks, prioritize effectively, and meet deadlines.

• Capacity to handle confidential information appropriately.

• Ability to work independently and collaboratively in a fast-paced environment.

• Strong written and verbal communication skills, along with interpersonal abilities.

• Ability to collaborate with remote cross-functional product teams.

• Competency in computer and technology literacy.

• Flexibility to engage in an international organization's processes and participate in global-time-zone conference calls.

• Willingness to work after hours and/or on weekends as needed for major deliverables or deadlines.

• Travel requirement of up to 10%.

• Capability to provide a dedicated, secure work area.

• Ability to ensure high-speed internet access/connectivity and maintain an office setup.

• Capacity to sit and use a computer keyboard for extended durations.

• Must reside in the continental US.

🏝️ Benefits

• Medical insurance.

• Dental insurance.

• Vision insurance.

• Disability insurance.

• Life insurance coverage.

• 401(k) savings plan.

• Paid family leave.

• 9 paid holidays per year.

• 17–27 days of Paid Time Off (PTO) annually, depending on level and length of service.

• Remote work arrangement.

• Dedicated, secure work area and high-speed internet/office setup provided by the worker.