Care Review Clinician

Company Description

HealthCare Support Staffing, Inc. (HSS), is a proven industry-leading national healthcare recruiting and staffing firm. HSS has a proven history of placing talented healthcare professionals in clinical and non-clinical positions with some of the largest and most prestigious healthcare facilities including: Fortune 100 Health Plans, Mail Order Pharmacies, Medical Billing Centers, Hospitals, Laboratories, Surgery Centers, Private Practices, and many other healthcare facilities throughout the United States. HealthCare Support Staffing maintains strong relationships with top providers in healthcare and can assure healthcare professionals they will receive fast access to great career opportunities that best fit their expertise. Connect with one of our Professional Recruiting Consultants today to see how a conversation can turn into a long-lasting and rewarding career!

Job Description

• 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 Molina 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 claims review. 

Qualifications

Candidate will 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. 

• Minimum 2-4 years of clinical practice.

• Minimum 1 year utilization review or medical claim review experience

• Active, unrestricted state nursing license in good standing

• 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       

Additional Information

If you are interested in applying to this position, please contact Brianne Salazar at (321)710-4799 and click the Green I’m Interested Button to email your resume.