Community Health Options
Payment Integrity Clinical Review Specialist
Community Health Options, Montgomery, Alabama, United States
Payment Integrity Clinical Review Specialist
With trillions of dollars spent on health care annually, in the United States, the potential for abuse is staggering. Even worse, the lives of millions of patients hang in the balance. As a Payment Integrity Clinical Review Specialist, you will help us target those responsible, minimize losses and protect those most vulnerable. Essential Functions And Responsibilities
Collaborate with the Payment Integrity (PI) team on healthcare fraud, waste, and abuse investigations Performs Quality Audits to include validation of accuracy and completeness of ICD, Rev Code, CPT, HCPCs, APR, DRG, POA, and all relevant coding elements. Audits can include inpatient, outpatient, and professional claims. Review medical records and claims on a pre and post pay basis for PI cases involving fraud, waste, or abuse Apply industry, state, and federal regulations and guidelines Assess findings to detect patterns of fraud, waste, and abuse Make accurate claim decisions based on policies, payment rules, coding guidelines, and clinical judgment JOB SPECIFIC KEY COMPETENCIES (KSAs)
Excellent interpersonal, verbal, and written communication skills required with excellent analytical and problem-solving skills. Detail oriented and ability to thrive in fast-paced work environment. An intermediate level of knowledge with Local, State & Federal laws and regulations pertaining to health insurance (Medicare, Medicare Advantage, Medicare Part D, Medicaid, Tricare, Pharmacy, and/or commercial health insurance) Advanced knowledge of Microsoft Office suite, including Word, Excel and PowerPoint. DIVERSITY, EQUITY, AND INCLUSION STATEMENT Community Health Options is committed to fostering, cultivating, and preserving a culture of diversity, equity, and inclusion (DEI). Our human capital is the single most valuable asset we have. The collective sum of individual differences, life experiences, knowledge, inventiveness, innovation, self-expression, unique capabilities, and talent our employees invest in their work represents a significant part of not only our culture, but our reputation and achievement as well. Community Health Options DEI initiatives are applicable, but not limited to, our practices and policies on recruitment and selection; compensation and benefits; professional development, and training; promotions; transfers; social and recreational programs, and the ongoing development of a work environment built upon the premise of DEI, which encourages and enforces:
Respectful, open communication and cooperation between all employees. Teamwork and participation, encouraging the representation of all groups and employee perspectives. Balanced approach to work culture through flexible schedules to accommodate varying needs of our people. Employer and employee contributions to the communities we serve to promote a greater understanding and respect for each other. Qualifications And Core Requirements
Experienced as RN licensed in state of residence Bachelor’s degree in business, healthcare administration, or other related functional area is required. Certified Clinical Documentation Specialist (CCDS) Certified Coding Specialist (CCS) Certified Fraud Examiner (CFE) preferred 3+ years of experience in a position processing medical claim auditing, payment integrity, and investigating fraud, waste, and abuse 5+ years of experience working in health care hospital and physician practices and/or health insurance environment 1+ years of experience conducting or managing comprehensive research to identify billing abnormalities, questionable billing practices, irregularities, and fraudulent or abusive billing activity A dedicated workspace with high-speed internet (=50 Mbps down / =10 Mbps up) and wired connectivity is required.
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With trillions of dollars spent on health care annually, in the United States, the potential for abuse is staggering. Even worse, the lives of millions of patients hang in the balance. As a Payment Integrity Clinical Review Specialist, you will help us target those responsible, minimize losses and protect those most vulnerable. Essential Functions And Responsibilities
Collaborate with the Payment Integrity (PI) team on healthcare fraud, waste, and abuse investigations Performs Quality Audits to include validation of accuracy and completeness of ICD, Rev Code, CPT, HCPCs, APR, DRG, POA, and all relevant coding elements. Audits can include inpatient, outpatient, and professional claims. Review medical records and claims on a pre and post pay basis for PI cases involving fraud, waste, or abuse Apply industry, state, and federal regulations and guidelines Assess findings to detect patterns of fraud, waste, and abuse Make accurate claim decisions based on policies, payment rules, coding guidelines, and clinical judgment JOB SPECIFIC KEY COMPETENCIES (KSAs)
Excellent interpersonal, verbal, and written communication skills required with excellent analytical and problem-solving skills. Detail oriented and ability to thrive in fast-paced work environment. An intermediate level of knowledge with Local, State & Federal laws and regulations pertaining to health insurance (Medicare, Medicare Advantage, Medicare Part D, Medicaid, Tricare, Pharmacy, and/or commercial health insurance) Advanced knowledge of Microsoft Office suite, including Word, Excel and PowerPoint. DIVERSITY, EQUITY, AND INCLUSION STATEMENT Community Health Options is committed to fostering, cultivating, and preserving a culture of diversity, equity, and inclusion (DEI). Our human capital is the single most valuable asset we have. The collective sum of individual differences, life experiences, knowledge, inventiveness, innovation, self-expression, unique capabilities, and talent our employees invest in their work represents a significant part of not only our culture, but our reputation and achievement as well. Community Health Options DEI initiatives are applicable, but not limited to, our practices and policies on recruitment and selection; compensation and benefits; professional development, and training; promotions; transfers; social and recreational programs, and the ongoing development of a work environment built upon the premise of DEI, which encourages and enforces:
Respectful, open communication and cooperation between all employees. Teamwork and participation, encouraging the representation of all groups and employee perspectives. Balanced approach to work culture through flexible schedules to accommodate varying needs of our people. Employer and employee contributions to the communities we serve to promote a greater understanding and respect for each other. Qualifications And Core Requirements
Experienced as RN licensed in state of residence Bachelor’s degree in business, healthcare administration, or other related functional area is required. Certified Clinical Documentation Specialist (CCDS) Certified Coding Specialist (CCS) Certified Fraud Examiner (CFE) preferred 3+ years of experience in a position processing medical claim auditing, payment integrity, and investigating fraud, waste, and abuse 5+ years of experience working in health care hospital and physician practices and/or health insurance environment 1+ years of experience conducting or managing comprehensive research to identify billing abnormalities, questionable billing practices, irregularities, and fraudulent or abusive billing activity A dedicated workspace with high-speed internet (=50 Mbps down / =10 Mbps up) and wired connectivity is required.
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