Senior Program Integrity & Medical Coding Reviewer

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

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.