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Clinical Reviewer
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Full-time
- Position Purpose: The Clinical Reviewer will be responsible for conducting clinical reviews of medical records during the course of fraud investigations, special investigations, claims reviews and / or other program integrity initiatives such as requests for information in support of proactive data analysis efforts.
- Perform the clinical review in Standard Claims Processing System files (e.g., medical records, prior authorization, UB / HCFA forms, provider contracts, etc.)
- Maintain chain of custody on all documents; follows confidentiality and security guidelines
- 5 to 7 years of experience as a clinical reviewer and working with ICD-9/10 CM, CPTs, HCPCS, Diagnostic Related Groups (DRGs), Prospective Payment Systems and Correct Coding Initiative
- Experience in Medicare Advantage Plan, managed care or government contractor (e.g.: ZPIC, UPIC, RAC, MAC, etc.)
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