Manager, Clinical Review

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

📋 Description

• Oversee the allocation of resources and outcomes of clinical assessments stemming from providers or claims flagged for possible fraud, waste, and/or abuse.

• Supervise the review and auditing procedures for improper billing practices.

• Formulate medical strategies to resolve billing discrepancies.

• Assess audit reports for precision and thoroughness.

• Communicate findings to Upper Management.

• Collaborate with providers and facilitate ongoing educational training on proper billing practices.

• Assist in legal proceedings initiated by the corporation, as well as state and federal authorities.

• Manage the execution of improvement initiatives for more effective and efficient auditing procedures.

• Partner with the medical management department to help shape medical policy based on coding research and medical record evaluations.

• Supervise and analyze cost-saving assessments.

• Convene with Medical Directors to affirm medical decisions and monitor cost savings derived from clinical denials.

• Lead and mentor a team of clinical investigators.

• Analyze and assess intricate Fraud, Waste & Abuse cases.

• Utilize clinical expertise to recognize trends, risks, and potential issues.

• Collaborate with providers and internal stakeholders on intricate cases.

• Promote healthcare integrity and the appropriate use of services.

• Execute additional responsibilities as assigned.

• Adhere to all policies and standards.

⛳️ Requirements

• A Bachelor's Degree in Nursing, a related field, or equivalent experience is required for Physical Health.

• At least 5 years of medical coding and/or nursing experience is required for Physical Health.

• Proficient understanding of medical terminology and research methods is required for Physical Health.

• Familiarity with CPT code billing is essential.

• Prior experience in managing cross-functional teams on large projects or supervisory roles, including hiring, training, task assignment, and performance management, is required.

• Clinical experience in a hospital or clinic environment, emergency room, and/or physician office is preferred for Physical Health.

• Certification as a Professional Coder, RN, or LPN is preferred and considered an advantage.

• Capability to review medical records and perform coding research.

• Ability to manage clinical investigators and complex healthcare integrity cases.

• Skill in collaborating with providers, Medical Directors, internal stakeholders, and legal entities.

• Compliance with all policies and standards is required.

🏝️ Benefits

• Competitive salary.

• Health insurance coverage.

• 401K retirement plan.

• Stock purchase options.

• Tuition reimbursement programs.

• Paid time off.

• Holiday pay.

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

• Additional incentive opportunities may be included in total compensation.

• Workplace flexibility.

• Support for accommodations.