Program Integrity Clinical Reviewer II

CareSource; Dayton (OH); Hybrid; USD 72,000 - 116,000; Full time

Job summary

CareSource is seeking a Program Integrity Clinical Reviewer II to evaluate medical records for compliance with documentation standards, CPT/HCPCS/ICD-10 coding, and medical policies in relation to claims.

The role supports prepayment, post-payment, and SIU teams, participates in audits, and develops training and corrective action plans while maintaining strict confidentiality of sensitive information.

Qualifications

• Bachelor of Science degree or equivalent experience required.
• Minimum of five (5) years clinical practice experience required.
• Significant experience auditing medical records against claims required.
• Current, unrestricted RN licensure in state of practice required.
• Certified Medical Coder (CPC, RHIT or RHIA) required at hire or within 18 months of hire date.
• FWA investigation and auditing experience preferred.

Responsibilities

• Review medical records to determine claim accuracy for payment.
• Support prepayment, post-payment, and SIU teams.
• Present identified clinical issues and research to Medical Directors and physician experts.
• Conduct or contribute to on-site audits and investigations of medical professionals and entities.
• Develop clinical and coding audit tools and training materials.
• Draft corrective action plans for clinical and coding deficiencies.
• Contribute to clinical/payment policy development with UM Committee.
• Collaborate with Pharmacy, Medical Management, Claims, Contracting, Case Management, and Legal.
• Maintain confidentiality of sensitive investigative information.
• Create and execute training materials and monthly audits of staff.
• Deliver training through presentations, quick reference tools, and digital media.
• Perform other job related instructions as requested.

Skills

Analytical skills

Attention to detail

Communication skills

Time management

Problem solving

Project management

Team collaboration

Education

Bachelor's degree or equivalent experience

Tools

Microsoft Word

Microsoft Excel

Microsoft PowerPoint

Job description

Job Summary:

The Program Integrity Clinical Reviewer II contributes to the investigative process by evaluating medical records, looking for correct documentation, trends, patterns, missing information, upcoding, unbundling, etc. in relation to clinical documentation, medical standards, and CPT, HCPCS and ICD-10 codes.

Essential Functions:

• Conduct claim reviews against medical records to determine claim accuracy for claims payment.
• This will support prepayment, post-payment, and SIU teams.
• Conduct meetings to present identified clinical issues and associated research to Medical Directors and physician experts for validation
• Conduct, participate or contribute to on-site audits and investigations of medical professionals, subcontractors and contracted entities
• Assist the audit and investigative teams in the development of clinical and coding based audit tools
• Draft proposed provider education and formal corrective action plans for clinical and coding deficiencies
• Provide SIU perspective to the development of clinical and payment policies and the Utilization Management Committee
• Collaborate with other departments including, but not limited to Pharmacy, Medical Management, Provider Relations, Claims, Contracting, Case Management, and Legal
• Responsible for maintaining confidentiality of all sensitive investigative information
• Develop and maintain SIU specific clinical and investigative training materials to include processes (SOPs)
• Create and execute monthly audits of investigative staff’s work to ensure processes are followed and to identify additional training opportunities
• Create, use and/or provide multiple training mediums such as presentations, quick reference tools, speakers, internet and state and federal resources, etc.
• Perform any other job related instructions as requested

Education and Experience:

Bachelor of Science Degree equivalent experience years of relevant experience is required Minimum of five (5) years clinical practice experience required Significant experience auditing medical records against claims is required Prior Fraud, Waste, Abuse (FWA) investigation and auditing experience preferred Medical research experience is preferred

Competencies, Knowledge and Skills:

CPT, HCPCS and ICD-10 coding knowledge is required Knowledge of Medicare/Medicaid/Managed Care preferred Proficient with Microsoft Office Word, Excel and PowerPoint Strong organizational and time management skills Broad-based clinical and medical coding knowledge Strong analytical skills with high attention to details Skill in negotiating issues and resolving problems High-level Investigative experience Training/teaching experience and demonstrated knowledge of adult learning environment Excellent written and verbal communication skills with adeptness to create, present and evaluate present department, role-focused teaching materials across topics Ability to communicate verbally and in written form with a variety of levels within the organization Critical decision making/problem solving skills Considerable skill set in planning and project management Ability to work independently and within a team environment Medical research background preferred

Licensure and Certification:

Current, unrestricted RN licensure in state of practice is required Certified Medical Coder (CPC, RHIT or RHIA) is required at time of hire or within 18 months of hire date

Working Conditions:

General office environment; may be required to sit or stand for extended periods of time

Compensation Range:

$72,200.00 - $115,500.00 CareSource takes into consideration a combination of a candidate’s education, training, and experience as well as the position’s scope and complexity, the discretion and latitude required for the role, and other external and internal data when establishing a salary level. In addition to base compensation, you may qualify for a bonus tied to company and individual performance. We are highly invested in every employee’s total well-being and offer a substantial and comprehensive total rewards package.

Compensation Type (hourly/salary):

Salary

Organization Level Competencies

• Fostering a Collaborative Workplace Culture
• Cultivate Partnerships
• Develop Self and Others
• Drive Execution
• Influence Others
• Pursue Personal Excellence
• Understand the Business

This job description is not all inclusive. CareSource reserves the right to amend this job description at any time. CareSource is an Equal Opportunity Employer. We are dedicated to fostering an environment of belonging that welcomes and supports individuals of all backgrounds.

#LI-SD1 Brand=CareSource The CareSource mission is known as our heartbeat. Just as we support our members to be the best version of themselves, our employees are driven by our mission to create a better world for members, stakeholders and providers. We are difference-makers who combine compassionate hearts with our unique business expertise to make every opportunity count. Each claim, each phone call, each consumer-centric decision is a chance to change the world for one member, and our employees look for ways to do that every day. The challenge is, there is no one right way to be the difference and we’re looking for people like you that will rewrite that definition every day. We do what it takes to form creative solutions that make our community and the world just a little better. Discover what it means to be #UniquelyCareSource.