Senior Clinical Investigative Consultant Meritain – Tpa
| Company | CVS Health |
|---|---|
| Location | Texas, USA, Waterbury, CT, USA, Arizona, USA, Minnesota, USA, Ohio, USA, Louisiana, USA, Michigan, USA, Illinois, USA |
| Salary | $67900 – $190344 |
| Type | Full-Time |
| Degrees | |
| Experience Level | Senior |
Requirements
- 5+ years’ experience in the HealthCare Industry conducting medical review/claim audit (Claims/Coding/Edit Development, medical reimbursement policy development)
- Command of Coding, edits, standard software edits, Facility and Professional formatted claim submissions
- Familiarity with Fraud, Waste and Abuse schemes within the HealthCare Industry
- Ability to apply ICD coding, CPT coding, have knowledge of CMS regulations
- Project work, or Business Analysis background with recognized teamwork skills and demonstrated success
- Strong communication skills with a broad range of individuals and groups, including members and provider.
Responsibilities
- Review provider medical records using coding criteria, state guidelines, and company policies for clinical appropriateness.
- Prepare a summary of findings to recommend next steps, including prepayment review, post payment review, and draft provider corrective action plans.
- Identify preemptive measures to prevent further fraudulent billing practices/schemes and manage complex investigations into suspected fraud, waste, and abuse (FWA).
- Conduct a comprehensive medical record audit to ensure the CPT/HCPCS or modifiers billed are consistent with medical record documentation.
- Handle complex coding reviews and provide detailed written summary of medical record review findings.
- Articulate findings to investigators, law enforcement, legal counsel.
- Review and discuss cases with Medical Directors.
- Independently research and accurately apply state or CMS guidelines related to the audit.
- Assist with investigative research related to coding questions, state, and federal policies.
- Identify opportunities for savings related to potential cases which may warrant a prepayment review.
- Maintain appropriate records, files, documentation, etc.
- Mentor teammates, providing training, coding, and record review guidance.
- Collaborate with investigators, data analytics and plan leadership on SIU schemes.
- Conduct high level, complex investigations of known or suspected acts of healthcare fraud, waste, and abuse.
- Document all appropriate case activity in case tracking system.
- Prepare written case summaries and make referrals to State and Federal Agencies within the timeframes required by Law.
- Provide Trial Testimony in support of Criminal or Civil proceedings.
- Act as management back-up and supports the team when the manager is out of the office.
Preferred Qualifications
- Data Management skills with ability to evaluate, as well as generate, reports as needed—an analytical and statistical background.