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Clinical Review Specialist, Payment Integrity Job in Dayton, Ohio

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Job Title: Clinical Review Specialist, Payment Integrity

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:230 North Main St Dayton 45402, OH, US
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 


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.  

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