Program Integrity Clinical Reviewer II

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