Care Review Clinician II

Location: Spokane, Washington
Posted On: 6/15/2017
Job Code: 7537_Care Reviewe_WA
Job Description
To provide clinical expertise in the application of medical and reimbursement policies within the claim adjudication process through claim review, medical record review and research. To provide expert knowledge in CMS, NCCI, AMA and other nationally published guidelines for correct coding and billing accuracy.

Essential Functions:-
• Evaluates medical records and/or medical notes providing clinical expertise on coding accuracy.
• Reviews for provider reconsideration requests related to claim edits and validation outcomes.
• Utilizes established criteria for review of complex medical claims and refers to Chief Medical Officer or Medical Director for determinations when criteria are not met
• Acting as a clinical resource, provides clinical review of claims to determine coding and billing accuracy and medical appropriateness of various types of provider claims.
• Reviews claims for correct billing and coding using Medicare Provider Manual guidelines. Documents clinical review summaries, bill audit findings and audit details in the data base.
• Identifies and reports quality of care issues to the Quality Management Department.
• Reports suspected member or provider fraud per Healthcare Policy.
• Identifies and refers members with special needs to the appropriate Healthcare program per policy/protocol.
• Participates in the development and implementation of proactive approaches to improve and standardize overall retrospective claims review.
Category:Non-IT  code:new
Job Requirements
• Preferred Experience in one of more of the following areas critical care, emergency medicine, surgical, pediatrics, advanced practice nursing, and billing and coding experience
• Great organizational skills
• Critical thinkers and the ability to make decisions using clinical background/knowledge
• Able to work independently
• Able to collaborate and work with peers to make decisions
• Knowledge of state and federal regulations
• In-depth Knowledge of ICD-9, CPT, and HCPTS
• Great Verbal and Written Communication Skills because they will be interacting with Medical Directors

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Contact Details
Zachary Maxey
E-mail Address