Home > Medical Coding Jobs > Ohio > Clinical Review Specialist, Payment Integrity Job in Dayton

Clinical Review Specialist, Payment Integrity Job in Dayton, Ohio

It is the responsibility of the job seeker to validate the information posted for each job. AAPC cannot validate or guarantee the accuracy of the information posted below.


Job Title: Clinical Review Specialist, Payment Integrity

Employer:CareSource
Type:Salaried Full-Time
Skills:Auditing,Claims,Coding,Nursing
Specialties:Managed care, Medicaid, Insurance
Required Certifications:RHIT or RHIA) is required at time of hire or must be obtained within 18 months of hire date,Certified Medical Coder (CPC
Required Experience:3 to 4 years
Location:Dayton, OH
Date Posted:1/23/2019

Role and Responsibility:

  • Responsible for Provider Prepay Program surveillance and utilization review ensuring that reimbursement is reasonable, medically necessary and of optimum quality and quantity by completing thorough review of medical documentation
  • Provide timely and accurate clinical review of medical records documentation and claims for overutilization of services or other billing aberrancies that, directly or indirectly, result in unnecessary cost to CareSource
  • Produce and submit detailed monthly prepayment medical record review activity and savings reports according to department established content and timelines
  • Develop and maintain SIU Provider Prepay Clinical Review materials to include processes (SOPs)
  • Contribute to investigative process by evaluating medical records documentation and medical standards
  • Interact with providers, office managers, medical director, outside vendors and state agency staff relationships
  • Develop and maintain knowledge of Medicaid/Medicare statutes and regulations for all states in which CareSource does business
  • Serve as main point of contact between SIU Provider Prepayment and Clinical Appeals Department
  • Serve as clinical liaison to SIU Fraud Claim Analysts, Medical Director and Fraud Examiners
  • Participate and  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 attributes and supportive references
  • Collaborate with other departments including, but not limited to IT, Appeals, Provider Relations, Claims, Contracting, Case Management, Operational Excellence and Legal
  • Use concepts and knowledge of CPT, ICD10, HCPCS, DRG, REV coding rules to analyze complex provider claims submissions
  • Responsible for maintaining confidentiality of all sensitive investigative information
  • Perform any other job related instructions as requested

Cross Functional Interactions:

  • Build strong working relationships with all departments impacted by Provider PrePay Review
  • Promotes collegial and collaborative working relationships focusing on Corporate Goal Alignment that impact quality, savings, program integrity, consumer experience and financials
  • Significant interaction and collaboration with Leadership Teams and Cross-Department Teams throughout CareSource will be essential for driving successful implementation and ongoing process improvements for Provider Prepay 

Education / Experience:

  • Bachelor’s Degree in Nursing (BSN) is required
  • Minimum of three (3) years of clinical nursing experience is required
  • Previous managed care, appeals and/or Medicaid experience is preferred
  • Significant experience in auditing/reviewing medical records against claims is required
  • Medical coding principles (CPT, HCPCS, ICD-9, CCI, OPPS) is preferred Experience with chart review, clinical review and quality assurance is preferred

Required Competencies / Knowledge / Skills:

  • Proficient , Microsoft Suite to include Word, Excel and Access
  • Knowledge of Facets Claim System
  • Firm understanding of basic medical billing and claims process
  • Strong interpersonal skills and high level of professionalism
  • Knowledge of Medicaid/Medicare/Exchange state and federal regulations is highly preferred
  • Excellent written and verbal communication skills
  • Ability to work independently and within a team environment
  • Effective problem solving skills with attention to detail
  • Effective listening and critical thinking skills
  • Clinical writing skills
  • Ability to develop, prioritize and accomplish goals
  • CPT, HCPCS and ICD-10 coding knowledge is required
  • Strong clinical background with attention to detail
  • Strong analytical skills
  • Ability to communicate verbally and in written form with a variety of levels within the organization

Licensure / Certification:

  • Current, unrestricted Registered Nurse (RN) license in state of practice is required
  • Certified Medical Coder (CPC, RHIT or RHIA) is required at time of hire or must be obtained within 18 months of hire date

Working Conditions:

  • General office environment; may be required to sit/stand for long periods of time 

Applying

To Apply, visit www.caresource.com/careers, click View Jobs, and then Search open Jobs using Keyword: 18-1936. 

OR, click on this link to the job posting:

Applications not accepted by email.  




Looking for Exhibiting Opportunities or Group Discounts?

Contact us at 844-825-1679.