Program Integrity Clinical Reviewer II

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

📋 Description

• Assess medical records for accurate documentation, identifying trends, patterns, missing information, upcoding, unbundling, and ensuring compliance with clinical documentation, medical standards, as well as CPT, HCPCS, and ICD-10 codes.

• Perform claim reviews in relation to medical records to verify claim accuracy for payment, supporting both prepayment, post-payment, and Special Investigations Unit (SIU) teams.

• Share identified clinical issues and research findings with Medical Directors and physician experts for validation.

• Conduct or contribute to on-site audits and investigations involving medical professionals, subcontractors, and contracted entities.

• Aid audit and investigative teams in creating clinical and coding-based audit tools.

• Draft proposed educational materials for providers and formal corrective action plans addressing clinical and coding deficiencies.

• Offer SIU insights regarding clinical and payment policies and participate in the Utilization Management Committee.

• Work collaboratively with Pharmacy, Medical Management, Provider Relations, Claims, Contracting, Case Management, Legal, and other departments.

• Ensure confidentiality of sensitive investigative information.

• Develop and maintain SIU-specific clinical and investigative training materials and Standard Operating Procedures (SOPs).

• Create and implement monthly audits of investigative staff work to verify adherence to processes and identify areas for training improvement.

• Develop, utilize, and provide training resources including presentations, quick reference tools, speakers, internet, and state and federal resources.

• Perform additional job-related tasks as assigned.

⛳️ Requirements

• A Bachelor of Science degree or an equivalent number of years of relevant experience is necessary.

• A minimum of five (5) years of clinical practice experience is required.

• Significant experience in auditing medical records against claims is essential.

• Prior experience in Fraud, Waste, and Abuse (FWA) investigations and auditing is preferred.

• Medical research experience is preferred.

• Knowledge of CPT, HCPCS, and ICD-10 coding is required.

• Familiarity with Medicare, Medicaid, and Managed Care is preferred.

• Proficiency in Microsoft Office applications including Word, Excel, and PowerPoint.

• Comprehensive knowledge of clinical and medical coding.

• Strong analytical skills with a keen attention to detail.

• Skillful in negotiating issues and resolving problems.

• High-level investigative experience is essential.

• Experience in training/teaching with demonstrated knowledge in adult learning environments.

• Excellent written and verbal communication skills with the ability to create, present, and evaluate teaching materials focused on the department and role.

• Capability to communicate effectively both verbally and in writing with various levels within the organization.

• Strong decision-making and problem-solving skills.

• Considerable planning and project management skills.

• Ability to work independently as well as collaboratively within a team environment.

• A current, unrestricted RN license in the state of practice is required.

• Certification as a Medical Coder (CPC, RHIT, or RHIA) is required at the time of hire or within 18 months of the hire date.

🏝️ Benefits

• A bonus linked to both company and individual performance may be available.

• A comprehensive total rewards package.

• An Equal Opportunity Employer environment that emphasizes belonging and support for individuals from all backgrounds.