Program Integrity SURS Clinician

Job Title

Develop a case based on a complaint and/or data profile while identifying the initial billing problem(s) related to medical and non-medical care programs.

Research and analyze all reports and other evidence obtained to determine if aberrant billing has occurred. Apply medical expertise to determine the requests of pertinent records based on review of the sample.

Collaborate with a variety of medical consultants relative to questionable billing practices related to medical necessity of services. Work with applicable program management staff, contract staff and other staff from agencies involved in case reviews and investigations.

Research and discern pertinent information from Medicaid provider manuals, medical coding and diagnosis publications, Medicaid publications/rules/regulations and other medical resources.

Analyze claims and encounter data using a robust computer profiling system to isolate and identify aberrancies and outliers. Produce spreadsheets and other documents to support analyses and findings from the investigations and reviews.

Conduct on-site inspections and assessments of provider facilities and procure medical records, equipment lists, employee records, etc. deemed necessary to conduct a thorough and complete review. Possess the interpersonal and professional skills necessary to interview providers and their employees. Verify all medical equipment including laboratory used to bill Medicaid.

Interview physicians, office and support staff or other provider types to obtain crucial information needed to complete the reviews. Document and summarize information from interviews and observations from on-sites.

Utilize expertise and knowledge to interpret documentation, procedure codes and diagnoses included in provider and recipient histories and associated reports.

Interpret claims and encounter histories by utilizing professional clinical publications such as the Current Procedural Terminology (CPT) manuals and companion guides, Healthcare Common Procedure Coding System (HPCS) and International Classification of Diseases (ICD) books.

Prepare and maintain documentation for cases. Communicate verbally as well as through written correspondence to providers, recipients, attorneys, etc. Complete and document items timely throughout the review/investigation process.

Receive, monitor and track monies recovered as a result of the reviews /investigations. Prepare financial memorandums and promissory notes for payments relating to caseloads.

Develop cases while conferring with staff from the Centers for Medicare and Medicaid (CMS), Federal Bureau of Investigations (FBI), Medicaid Fraud Control Unit (MFCU), Office of Inspector General (OIG), United States Attorney and other governmental agencies participating in the review /investigations.

Formulate and research information by utilizing the Medicaid Management Information System (MMIS), Microsoft Word, Excel, Access and other applicable software.

Supply information needed for the statistical extrapolation process for overpayments.

Coordinate, plan, schedule and participate in Informal Hearings with LDH, providers, attorneys, analysts and others involved in the process. Prepares for and testifies in appeal procedures before an Administrative Law Judge and appears in court as an expert witness on behalf of Medicaid.

Recommend policy clarifications and changes based on observations and review findings.

Perform other related duties as assigned.

Qualifications Required:

• Possession of a valid Louisiana Registered Nurse license to practice professional nursing.
• Three years of professional nursing experience or experience with claims and/or medical record auditing experience with a public and/or private insurance entity.
• Excellent analytical skills, effective organizational and time management skills.
• Excellent communication skills both oral and written.
• Proficient in the use of Microsoft Office products.

Desired:

• Advanced Degree.
• Five years of professional experience with claims and/or medical record auditing experience with a public and/or private insurance entity.
• Five years of professional nursing experience.
• Three years of professional experience with Louisiana Medicaid policies, publications and rules.
• Professional industry auditing certification (CPC, CPMA, CIC, CFE) and/or other medical certification.