Job description

Job Description Summary-Hybrid Remote work/Office work

Role:
The Clinical Claims Reviewer is responsible for the coordination, investigation, documentation and resolution of provider inquiries and reconsiderations ensuring compliance with payer policies and procedures and other regulatory agency standard guidelines. Handles review of procedures for pre/post-authorization based on medical necessity, medical and managed standards of care, and benefit determinations. Reviews denied claims for CPT, ICD, HCPCS coding, bundling issues and modifier utilization. Utilizes knowledge of correct coding guidelines, CMS Correct Coding Initiative edits, Health Coding policies, Clinical Care Services Medical Policies and group benefits to determine appropriate claim approval/denials. Provides justifications for denials to providers. Identifies trends in provider billing/coding errors and utilizes findings to create cost saving review opportunities.

Qualifications:

• Current LPN licensure in the state of Florida, or current licensure from another state plus a temporary Florida permit
• Minimum of two (2) years of hospice, palliative care, home health primary, and specialty care experience
• Familiarity with Medicare, Medicaid, commercial and CMS managed care initiatives
• Familiarity with CMS regulations and standards
• Experience in Microsoft Outlook, Excel and Word
• Ability to prioritize and multi-task independently with little supervision or loss of focus
• Must be self-motivated and service oriented
• Excellent written and verbal communication skills
• Ability to work in a team environment.

Competencies:

• Satisfactorily complete competency requirements for this position

Responsibilities of all employees:

• Always represent the Company professionally through care delivered and/or services provided to all clients.
• Comply with all State, federal and local government regulations, maintaining a strong position against fraud and abuse.
• Comply with Company policies, procedures, and standard practices.
• Observe the Company's health, safety, and security practices.
• Maintain the confidentiality of patients, families, colleagues, and other sensitive situations within the Company.
• Use resources in a fiscally responsible manner.
• Promote the Company through participation in community and professional organizations.
• Participate proactively in improving performance at the organizational, departmental, and individual levels.
• Improve own professional knowledge and skill level.
• Advance electronic media skills.
• Support Company research and educational activities.
• Share expertise with co-workers both formally and informally.
• Participate in Quality Assessment and Performance Improvement activities as appropriate for the position.

Job Responsibilities:

• Records and reviews claims to make payment determinations based on Insurance coverage, coding, and utilization of services and practice guidelines for Medicare A and Physician Office and Professional Services, Ambulance Services, Laboratory, and other areas.
• Performs first and second level of Medical Review in determination of claims payment review.
• Makes clinical judgment decisions based on clinical experience.
• Conducts in-depth claims analysis utilizing ICD-10-CM, CPT-4, and HCPCS Level II and CPT coding along with analysis and processing Medicare claims.
• Performs medical claim reviews for one or more of the following: claims for medically complex services, services that require preauthorization, predetermination, requests for appeal or reconsideration, referrals for potential fraud and abuse, and correct coding for claims and operations.
• Makes reasonable charge payment determinations based on clinical medical information and established criteria, protocol sets, or clinical guidelines. Documents medical rationale to justify payment or denial of services and supplies. Determines medical necessity, appropriateness, reasonableness, and necessity for coverage and reimbursement.
• Meets quality and production standards.
• Ensures departmental compliance with quality managements system and ISO requirements.
• Monitors processes’ timeliness in accordance with contractor standards.
• Utilizes electronic health information imaging and inputs medical review decisions by electronic database module.
• Provides electronic documentation of findings and conclusions with determinations of claims payment appropriateness in review tool fields.
• Engages with staff and leadership in a manner that supports department’s mission, vision, and values.
• Promotes, acts, and collaborates as a unified team member to drive system alignments.
• Provides education to non-medical staff through discussions, team meetings, classroom participation, and feedback.
• Performs other duties as assigned.

Job Type: Full-time

Pay: $17.85 - $24.92 per hour

Benefits:

• 401(k)
• 401(k) matching
• Dental insurance
• Employee assistance program
• Flexible spending account
• Health insurance
• Life insurance
• Paid time off
• Tuition reimbursement
• Vision insurance

Schedule:

• 8 hour shift
• Day shift
• Monday to Friday

Ability to commute/relocate:

• Temple Terrace, FL 33637: Reliably commute or planning to relocate before starting work (Required)

Work Location: Hybrid remote in Temple Terrace, FL 33637

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