Clinical Reviewer Job at DOCTORS HEALTHCARE PLANS, INC., Coral Gables, FL

dlBqamg2UXZJa2Uxdi9EK2xneTE1cnd5WUE9PQ==
  • DOCTORS HEALTHCARE PLANS, INC.
  • Coral Gables, FL

Job Description

Position Purpose:  The Clinical Reviewer serves as a subject matter expert in the clinical review of claims, claim disputes, appeals and FWA special investigations

Responsibilities:
  • Review of facility claim disputes including clinical records, itemized bills, prior authorizations, concurrent review, coding guidelines and provider compensation to determine appropriateness of medical necessity and coverage
  • Reference MCG guidelines, LCD/NCD’s and CMS guidelines to make clinical determinations
  • Present reviewed cases to Medical Director
  • Resolve prior authorization issues derived from developed claims
  • Utilize internal system, external platforms and appropriate state and federal guidelines to research potential FWA
  • Write FWA Investigative Summary Report for Special Investigations, and provide support for findings and recommendations
  • Comply with the CMS Program Integrity Manual and Statement of Work guidelines
  • Maintains appropriate documentation on all claim reviews according to departmental guidelines and procedures
  • Understand and maintain HIPAA confidentiality and privacy standards when completing assigned work
  • Collaborate with other departments to integrate best practices and enhance overall medical management processes 
  • Meet performance goals established for the position
  • Performs additional duties and responsibilities as assigned by management
Qualifications:
  • Minimum 5-7 years of experience as a clinical reviewer of facility claims in a Medicare Advantage environment, managed healthcare or government contractor
  • Knowledge of Medicare Advantage, CMS and AHCA regulatory requirements, as well as appl icable industry-based standards
  • Clinical experience within an acute care setting
  • Comprehensive understanding of the claim review process including clinical record review, and a broad knowledge of applicable processes, procedures and billing guidelines.
  • Proven track record in the analysis of clinical records, claim and FWA audits, utilization review and quality assurance
  • Advanced knowledge of clinical terminology such as MCG guidelines, LCD’s/NCD’s, ICD-9/10, DRG’s, OPPS, CPTs, HCPCS, Correct Coding Initiative and Final Rule
  • Outstanding investigative and research skills
  • Able to thrive in a complex, high-pressure environment
  • Strong analytical and critical thinking competencies
  • Excellent written and verbal communication skills
  • High-degree of computer literacy and advanced Excel spreadsheets for operational data analysis and reporting
Education:
  • Bachelor’s degree in Nursing or equivalent
  • A ctive and unrestricted RN or LPN license or equivalent
  • Coding Certification preferred (RHIA, RHIT, Inpatient Coding Credential – CCS/CIC, CCDS or CPC)
Note:  This description indicates, in general terms, the type and level of work performed and responsibilities held by the team member(s).  Duties described are not to be interpreted as being all-inclusive or specific to any individual team member.   

No Third Party Agencies or Submissions Will Be Accepted.   

Our company is committed to creating a diverse environment. All qualified applicants will receive consideration for employment without regard to race, color, religion, gender, gender identity or expression, sexual orientation, national origin, genetics, disability, age, or veteran status. DFWP   

Opportunities posted here do not create any implied or express employment contract between you and our company / our clients and can be changed at our discretion and / or the discretion of our clients. Any and all information may change without notice. We reserve the right to solely determine applicant suitability. By your submission you agree to all terms herein.

 

Job Tags

Full time, Contract work, For contractors,

Similar Jobs

Gpac

Marine Mechanic, Boat Repair Job at Gpac

Immediate opening for Marine Technician. Relocation to a Midwest Tourist destination required! Marinas, sales, service, storage, boat rentals, pro-shops, and specialty retail stores. Excellent pay and benefits About the position: Marine Technician: Demonstrates... 

Providence Health & Services

Patient Care Technician Job at Providence Health & Services

 ...Patient Care Technician at Providence Seaside Hospital. This posting represents an on-call, variable shift opening which start at 7am...  ...reasons. These reasons can include changes of Legal Employer, FTE, Union, location, time-off plan policies, availability of health and... 

History Factory

Public Affairs Historical Services Specialist - VA Based Job at History Factory

About History Factory Since 1979, History Factory has been driven by the pioneering idea of making an organizations history more useful for driving its business. Today, many of the worlds best enterprises turn to History Factory for unparalleled expertise at the ...

Hustle Notice Biz

Entry Level Events Assistant Job at Hustle Notice Biz

 ...Position: Entry Level Events Assistant Location: Toledo, OH Employment Type: Full-Time Description Role Overview: We are seeking an enthusiastic and passionate Entry Level Events Assistant to join our dynamic team. This is an exciting opportunity for... 

Aramark

Food Service Director Job at Aramark

 ...The Food Service Director is a management position responsible for developing and executing dining solutions to meet customer needs and tastes. Oversees and manages dining operations where customers order prepared foods from a menu. Compensation Data COMPENSATION...