| 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