Manager, Clinical, Coding Review

This is a fully remote position, open to applicants in Florida, +2 more states.

📋 Description

• Provide strategic direction for teams involved in advanced, intricate claim evaluations.

• Ensure accuracy in reviews, compliance with regulations, and the achievement of payment integrity objectives.

• Analyze performance patterns and standardize processes along with review methodologies.

• Offer actionable insights by utilizing ICD-10, CPT/HCPCS coding, and clinical guidelines.

• Monitor and enhance business processes and systems related to billing and claims payment integrity.

• Lead and guide teams performing advanced coding and clinical validation assessments.

• Create and uphold standardized documentation that supports business goals and ensures consistent review outcomes.

• Collaborate with cross-functional stakeholders to pinpoint process enhancements and implement innovative solutions.

• Assign priorities, establish goals, and coordinate daily activities of the team.

• Maintain open communication through regular one-on-one and team meetings.

• Establish and manage the complete lifecycle of the Payment Integrity audit program.

• Set the strategic direction for audits, manage and develop teams, and ensure compliance with regulatory, contractual, and organizational standards.

• Apply ICD-10 coding, clinical guidelines, Centene/Health Plan policies, CMS updates, state regulations, and contractual obligations to review results.

• Analyze audit trends and DRG adjustments to facilitate scalable program development and identify new review opportunities.

• Oversee the expansion into new complex review types and integrate review protocols for audit operations.

• Perform additional duties as required and adhere to all policies and standards.

⛳️ Requirements

• An Associate's Degree in health information management, Nursing, or a related discipline is required.

• A minimum of 5 years of managerial/supervisory experience is required.

• At least 8 years of experience in complex medical claim review is essential.

• A minimum of 3 years of DRG review experience is required.

• At least 3 years of experience in Clinical Documentation Improvement is necessary.

• Proficiency in ICD-10-CM/PCS, MS-DRG, and APR-DRG is required.

• Proficiency in Readmission, APC, EAPG, and other review types is necessary.

• One of the following credentials is required: RHIA, RHIT, CCS, Clinical Inpatient Coder (CIC), or Certified Clinical Documentation Specialist (CCDS).

• CDIP certification is preferred.

• RN state licensure and/or compact state licensure combined with a coding credential is preferred.

• Authorization to work in the U.S. without employment-based visa sponsorship, now or in the future, is required.

• Willingness to travel up to 25% is necessary.

🏝️ Benefits

• Competitive compensation.

• Health insurance coverage.

• 401K retirement plans.

• Stock purchase options.

• Tuition reimbursement programs.

• Paid time off along with holidays.

• Flexible work arrangements including remote, hybrid, field, or office schedules.

• Additional incentives may be included in the total compensation package.