Program Integrity Clinical Reviewer II (Readmission experience preferred)

📋 Description

• • Conduct claim reviews against medical records to determine accuracy for claims payment, supporting prepayment, post-payment, and SIU teams with an emphasis on readmission patterns.
• • Evaluate clinical documentation for compliance with medical standards, CPT, HCPCS, and ICD-10 coding practices, identifying issues such as upcoding, unbundling, missing information, and documentation discrepancies.
• • Present identified clinical and coding issues to Medical Directors and physician experts for validation during formal review meetings.
• • Participate in or lead on-site audits and investigations of medical professionals, subcontractors, and contracted entities to ensure regulatory and contractual compliance.
• • Assist in the development of clinical and coding-based audit tools to improve detection of fraud, waste, and abuse (FWA) in claims processing.
• • Draft provider education materials and formal corrective action plans to address identified clinical and coding deficiencies.
• • Contribute SIU perspective to the development of clinical policies, payment methodologies, and Utilization Management Committee decisions.
• • Collaborate cross-functionally with Pharmacy, Medical Management, Provider Relations, Claims, Contracting, Case Management, and Legal departments to align investigative efforts.
• • Maintain strict confidentiality of all sensitive investigative and patient information in compliance with HIPAA and organizational protocols.
• • Develop and maintain SIU-specific clinical and investigative training materials, including standard operating procedures (SOPs), presentations, quick-reference guides, and digital resources.
• • Conduct monthly audits of investigative staff work to ensure adherence to processes and identify areas for targeted training and performance improvement.
• • Create and deliver training across multiple mediums, including in-person sessions, online modules, and state/federal resource referrals, tailored to adult learning environments.
• • Perform additional job-related duties as assigned, including participation in internal audits, policy reviews, and compliance initiatives.
• • Apply strong analytical skills and high attention to detail to detect trends, patterns, and anomalies in medical records and claims data.
• • Communicate complex clinical and coding findings clearly and professionally to diverse audiences, from frontline staff to executive leadership.
• • Demonstrate proficiency in project management, time management, and independent work while effectively contributing to team objectives.
• • Utilize Microsoft Office Word, Excel, and PowerPoint to document findings, create reports, and develop training materials.
• • Apply critical thinking and problem-solving skills to resolve complex coding and clinical compliance issues.
• • Maintain an understanding of Medicare, Medicaid, and Managed Care reimbursement models and regulatory frameworks.
• • Engage in ongoing medical research activities to support audit findings and improve investigative methodologies.