Medical Compliance Auditor

DaMar Staffing; Bellaire (TX); On-site; USD 65,000 - 90,000; Full time

Job summary

Texas Children's Health Plan seeks a Medical Compliance Auditor to review and approve or deny medical claim appeals, performing clinical audits of medical records supporting billed services.

Role requires strong clinical judgment, knowledge of Medicaid rules, and the ability to collaborate with medical directors and staff to ensure appropriate, compliant care decisions.

Qualifications

• Required 3 years clinical experience in the applicable field according to the license.
• 4 years of Medical Auditing experience.
• Active RN or LVN licensure in Texas or licensure compact.

Responsibilities

• Assess treatment plans and medical necessity for services billed.
• Review and adjudicate medical claim appeals.
• Conduct clinical and coding reviews on medical claims.
• Consult with medical directors and staff regarding patient history and care needs.
• Document findings and prepare audit reports with recommendations.
• Coordinate with SIU for cases requiring action.
• Ensure compliance with Medicaid managed care and fraud guidelines.
• Provide education and outreach to providers as needed.

Skills

LVN Licensure

RN Licensure

CPC Certification

Clinical auditing

Medical record review

Education

Associate's Degree in Nursing

Technical Diploma in Vocational Nursing

Bachelor's Degree in Nursing (Preferred)

Job description

We are searching for a Medical Compliance Auditor - someone who works well in a fast-paced setting. In this position, you will review and approve or deny medical claim appeals and perform clinical audits of medical records submitted in support of services billed by providers. This process includes clinical judgment, utilization review, application of product benefits, understanding of regulatory requirements for Medicaid managed care and fraud and abuse, and verification of medical necessity utilizing nationally recognized criteria.

Think you've got what it takes?

Job Duties & Responsibilities

• Assess the treatment plan, clinical information, and medical necessity of all requested services
• Utilizes established criteria to appropriately review billed services within established timeframe required.
• Consults with medical directors and clinical staff regarding patient's history and current care needs and whether services billed were appropriate.
• Refers case failing medical necessity criteria to the Special Investigations Unit (SIU) Director and SIU Workgroup for review and a recommendation for action.
• Telephonic follow-up with the provider's office to request additional information as needed.
• Completes timely entry of information into electronic file including a chart with detailed findings of the review and a report summarizing the results of the audit.
• Evaluate benefit coverage and regulatory guidelines pertinent to decision making for each investigation.
• Perform Clinical and Coding Review on Medical Claim Appeals.
• Assess and process all education and recoupment letters after Special Investigative Committee review decision.
• Facilitates provider communication and education.
• Liaisons with internal staff members.
• Perform Clinical Review and make recommendation on Audit Pass/Fail.
• Ongoing assessment for quality indicators and concerns.

Skills & Requirements

• Required Associate's Degree in Nursing or
• Technical Diploma in Vocation Nursing
• Preferred Bachelor's Degree in Nursing
• Required LVN - Lic- Licensed Vocational Nurses Texas Board of Nursing or Nursing Licensure Compact or
• RN-Lic-Registered Nurses Texas Board of Nursing or Nursing Licensure Compact
• Preferred CPC-Cert-Cert Professional Coder Americal Academy of Professional Coders
• Required 3 years Clinical experience in the applicable field according to the license (LVN or RN)
• 4 years of Medical Auditing experience.

ABOUT US

Founded in 1996, Texas Children's Health Plan is the nation's first health maintenance organization (HMO) created just for children. We provide STAR/Medicaid and Children's Health Insurance Program (CHIP) to pregnant women, teens, children and adults in Houston and surrounding areas. Currently, the Health Plan has more than 375,000 members who receive care from our network of more than 1,100 primary care physicians, 3,200 specialists, and 70 hospitals. Texas Children's Health Plan is also the largest combined STAR/CHIP Managed Care Organization in the Harris County service area.

To join our community of 15,000+ dedicated team members, visit texaschildrenspeople.org for career opportunities.

Texas Children's is proud to be an equal opportunity employer. All applicants and employees are considered and evaluated for positions at Texas Children's without regard to mental or physical disability, race, color, religion, gender, national origin, age, genetic information, military or veteran status, sexual orientation, gender identity, marital status or any other protected Federal, State/Province or Local status unrelated to the performance of the work involved.