Care Review Clinician

Company Description

Integrated Resources, Inc., is led by a seasoned team with combined decades in the industry. We deliver strategic workforce solutions that help you manage your talent and business more efficiently and effectively. Since launching in 1996, IRI has attracted, assembled and retained key employees who are experts in their fields. This has helped us expand into new sectors and steadily grow.

We’ve stayed true to our focus of finding qualified and experienced professionals in our specialty areas. Our partner-employers know that they can rely on us to find the right match between their needs and the abilities of our top-tier candidates. By continually exceeding their expectations, we have built successful ongoing partnerships that help us stay true to our commitments of performance and integrity.

Our team works hard to deliver a tailored approach for each and every client, critical in matching the right employers with the right candidates. We forge partnerships that are meant for the long term and align skills and cultures. At IRI, we know that our success is directly tied to our clients’ success.

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.

• 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 Molina Healthcare program per policy/protocol.

• Participates in the development and implementation of proactive approaches to improve and standardize overall retrospective.

Qualifications

• clinical experience from a hospital (Preferred) .

• Min. 2- 3 years clinical nursing experience .

• 1 year of utilization review or medical claim review .

• RN License Required .

• Preferred Experience in one of more of the following areas critical care, emergency medicine, surgical.

• paediatrics, 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 .

Additional Information

All your information will be kept confidential according to EEO guidelines.