POSITION SUMMARY

　　The Clinical Reviewer is responsible for reviewing claims based on provider and health plan contractual agreements and claims processing guidelines. Analyze complex, unrelated data and extract valuable insights into summarized views and reports for review by Health Plan Operations. Is a role model and subject matter expert in claims adjudication, claims audit and monitoring, provider billing and reimbursement policies. This position serves as a key contributor to Health Plan Operations in order to maintain its relations with vendor partners while upholding contracts and confirming reimbursement objections are achieved.

　　PRIMARY ACCOUNTABILITIES

　　Investigate, review and provide clinical and/or coding expertise in the application of medical and reimbursement policies within the claim adjudication process through file review.Perform clinical coverage review of claims, which requires interpretation of state and federal regulations, applicable benefit language, medical and reimbursement policies and coding requirements and consideration of relevant clinical information on aberrant billing patterns.Identify aberrant billing patterns and trends, evidence of fraud, waste or abuse and recommend providers for payment review.Knowledge of and the ability to identify the ICD-10-CM/PCS code assignment, code sequencing, and discharge disposition, in accordance with CMS requirements, Official Guidelines for Coding and Reporting, and Coding Clinic guidance.Prepare and submit findings with clear, concise and accurate rationales.Collaborate with Legal Department during case development, pursuit of recovery, presentation of findings and legal proceedings.Maintain and manage daily case review, assignments independently with a high emphasis on quality feedback to leadership.Collaborate and assist with Health Plan FDRs/Delegated Entities to maintain integrity through direct oversight in meeting regulatory and contractual requirements.Act as a technical expert in handling complaints and other escalated issues from internal customers.Assist in audit preparation, including routine and ad-hoc regulatory audits as directed by HFHP Corporate Integrity.MINIMUM QUALIFICATIONS**Education:Associates Degree in Business, Healthcare or related field.Certification:Coding certification (any one of or a combination of the following): * Registered Health Information Administrator (RHIA) * Registered Health Information Technician (RHIT) * Certified Coding Specialist (CCS) * Certified Outpatient Coder (COC) * Certified Inpatient Coder (CIC) and/or * Certified Professional Coder (CPC)Work Experience in lieu of Education:Five years’ experience with healthcare claims, claims processing, claims editing, coordination of benefits, overpayment identification, investigation and/or auditing.Additional Knowledge/Skills/Abilities: * Extensive knowledge of CPT, HCPCS, ICD-10 codes sets, DRG and CMS billing guidelines. * Knowledge of managed care and insurance programs, provider payment structure, including CMS, Federal, State statutes and regulations. * Must possess a strong body of knowledge in relation to anatomy physiology, medical terminology, and the disease process to be adept in analyzing and assessing medical records, billing records, and other confidential protected health information. * Ability to research, analyze and communicate regulatory requirements. * Strong organization and analytical skills, with attention to detail. * Excellent oral and written skills. * Working knowledge of Microsoft Office, Excel skill including ability to create/edit spreadsheets, use sort/filter function, and perform data entry. PREFERRED QUALIFICATIONS

　　Education:Bachelor’s Degree in Business, Healthcare or related field.Licensure:RN licensed in the State of Florida or Compact License.

　　PHYSICAL REQUIREMENTS Majority of time involves sitting or standing; occasional walking, bending, and stooping. * Long periods of computer time or at workstation. * Light work that may include lifting or moving objects up to 20 pounds with or without assistance. * May be exposed to inside environments with varied temperatures, air quality, lighting and/or low to moderate noise. * Communicating with others to exchange information. * Visual acuity and hand-eye coordination to perform tasks. * Workspace may vary from open to confined; on site or remote. * May require travel to various facilities within and beyond county perimeter; may require use of personal vehicle.

　　Job: *Operations

　　Organization: *HF Administrative Plan Inc

　　Title: Clinical Reviewer - Payment Integrity

　　Location: Florida - Brevard County-Melbourne

　　Requisition ID: 070660