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Clinical Code Review Specialist Job in San Ramon, California

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Job Title: Clinical Code Review Specialist

Employer:Hill Physicians Medical Group
Location:2409 Camino Ramon San Ramon 94583, CA, US
Date Posted:12/13/2018

Job Description


To provide timely clinical and coding review of claims and claims appeals related to CPT, HCPCS and/or ICD-10 coding, to ensure accuracy of modifiers, place of service and/or date of service and to make processing recommendations per established clinical and/or coding criteria/conventions. To provide support and consultation to various Internal Departments as a Clinical Code Resource and in processing of memorandums of understanding (MOU).


Job Responsibilities


Perform clinical claims review and evaluate billed services for coding accuracy and appropriateness while meeting claim turn around times(TAT) and maintaining unit production goals, utilizing various resources such as Hill Physicians Guidelines, Health plan policies/guidelines, Milliman Care Guidelines, ClaimCheck, CPT, Encoder, etc. and obtaining additional medical information as necessary.

Manage/prioritize claims related issues from various sources such as electronic queues, e-mail, fax requests, Call Tracker requests (CTs) and daily claims reports.

Collaborate with designated physician leaders/Medical Management Teams for clinical support decisions.

Update/modify authorizations according to review findings and clearly document necessary claims processing recommendations to ensure proper payment of the claim or claim appeal.

Review retroactive authorization requests according to Health plan policies/guidelines, Hill Physicians policies and operational processes, including member history review, Milliman criteria, as well as obtaining additional information, and collaborating with physician leaders, designated Case Managers, or Prior Authorizations Nurses when necessary. 

Provide coverage and support for the MOU (Memorandum of Understanding) Coordinator as needed: Prepare and coordinate the MOU process including contacting the rendering provider’s office, negotiating rates and sending out the agreement letter according to Hill Physicians policies and operational processes.

Participate in internal workgroups as a medical/clinical code review expert and complete assigned projects to meet workgroup objectives.

Provide coding and claims review support to providers and all interdepartmental staff.

Actively support the Clinical Code Review Unit audit process and participate in staff education activities and training.

Track and trend claim and authorization discrepancies with communication to appropriate departments, supervisors and managers, and assist with provider education as necessary.

Assist interdepartmental staff with coding/claims review questions/issues & provide education & training as appropriate.

Other duties and projects as assigned.


Required Experience


Active, unrestricted California licensure: RN, LVN, RHIT/RHIA, or CPC/CCS/CCS-P certification preferred.

 Minimum 3 years clinical nursing experience; or minimum 2 years medical coding experience with strong understanding of anatomy & physiology and medical terminology (proof of passing score in A&P/Medical Terminology courses preferred).

Claims review or related managed care experience, minimum one year required.

Strong knowledge/understanding of CPT, HCPCS and ICD-10 coding required.

Strong knowledge/understanding of RBRVS-based and Medi-Cal fee schedules or payment systems required.

Understanding of the National Correct Coding Initiative and CPT coding rules/standards.

Ability to communicate and work with a variety of customers, including internal and external physicians, in a professional and articulate manner.

Proficient with various internet resources and routine software applications, including Microsoft Office. Competence in Excel preferred

Excellent organization, verbal & written communication skills

Strong ability to work well independently and as part of a team.



Additional Information


Hill Physicians is an Equal Opportunity Employer


Please apply directly to our website:  https://primed.wd1.myworkdayjobs.com/en-US/PriMed/job/San-Ramon---Bishop-Ranch-CA/Medical-Review-Specialist---SR-18-167_R371 

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