Clinical Reviewer (RN)

Job Description

Job Description

Clinical Reviewer (RN)
Hybrid Schedule: 3 days on-site
*This is a 6-month contract position with the possibility for other opportunities 

Description:
The RN Clinical Reviewer will independently review/audit medical records associated with claims and work in a team environment on fraud, waste, and abuse and program compliance issues for engagements with government healthcare programs, including primarily the Medicaid and Medicare programs.

Responsibilities:

• Utilizing healthcare knowledge and experience to review medical records for various types of medical services for accuracy, completeness, and consistency with professional standards and compliance with billing and coding requirements
• Documenting and reporting findings of reviews and audits in accordance with professional standards and project protocols
• Participating in on-site field examinations and desk reviews of providers to audit clinical documentation
• Interpreting and analyzing health care data
• Working in a team environment to develop new audit recovery projects
• Working with state client personnel on health care reimbursement and compliance issues, including recommending changes and improvements to policies to ensure provider compliance
• Working collaboratively with the medical director and other clinical staff in the development and management of fraud, waste, and abuse detection and other compliance projects
• Developing and maintaining general knowledge of reimbursement regulations, provider billing manuals, and other Medicaid policies for claim payment compliance reviews and documentation to support current audit findings
• Maintaining security of and confidentiality of all protected health information (PHI)
• Participating in and contributing to quality management systems
• Additional responsibilities as assigned

Required Skills/Knowledge/Experience:

• Minimum three years of clinical documentation review experience, utilization management review experience, or health care claims auditing experience
• Knowledge and experience in detecting and investigating health insurance fraud, waste, and abuse
• Knowledge of healthcare coding principles to include ICD-9, ICD-10, CPT, HCPCS, RUGS, and DRG
• Experience and knowledge of state and federal healthcare regulations, including reimbursement and coverage policies
• Experience in quality improvement projects desired
• Proficient use of applicable software tools, including Microsoft Windows, Word, Excel, and Access
• Strong analytical and problem-solving skills
• Excellent communication skills, including written and verbal, including ability to present to large or small groups
• Self-directed and motivated, with ability to work independently under general instructions
• Ability to work in a team environment and manage multiple deadlines and prioritize assignments
• Well organized with a high degree of accuracy and attention to detail
• Must be able to travel based on client and business needs
• Not currently sanctioned or excluded from any program operated by federal or state agencies, including Medicare and Medicaid

Education/Certifications:

• Bachelor's degree in nursing required (Associate's Degree from accredited nursing school with four or more years of additional clinical experience may be substituted in lieu of a bachelor's degree)
• Current Registered Nurse (RN) license in good standing
• Certified Professional / Hospital Coder Certification/ Clinical Documentation Specialist Certification (CPC, CIC, COC, CPMA, CCS, CCS-P, RHIA, RHIT, CCDS, CDIP ) preferred or proof that certification will be obtained within twelve months

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