- To provide clinical expertise in the application of medical and reimbursement policies within the claim adjudication process through claim review, medical record review and research.
- To provide expert knowledge in CMS, NCCI, AMA and other nationally published guidelines for correct coding and billing accuracy.
- Evaluates medical records and/or medical notes providing clinical expertise on coding accuracy.
- Reviews for provider reconsideration requests related to claim edits and validation outcomes.
- Utilizes established criteria for review of complex medical claims and refers to Chief Medical Officer or Medical Director for determinations when criteria are not met .
- Acting as a clinical resource, provides clinical review of claims to determine coding and billing accuracy and medical appropriateness of various types of provider claims.
- Reviews claims for correct billing and coding using Medicare Provider Manual guidelines. Documents clinical review summaries, bill audit findings and audit details in the data base.
- Identifies and reports quality of care issues to the Quality Management Department.
- Reports suspected member or provider fraud per Healthcare Policy.
- Identifies and refers members with special needs to the appropriate Molina Healthcare program per policy/protocol.
- Participates in the development and implementation of proactive approaches to improve and standardize overall retrospective.
- clinical experience from a hospital (Preferred) .
- Min. 2- 3 years clinical nursing experience .
- 1 year of utilization review or medical claim review .
- Preferred Experience in one of more of the following areas critical care, emergency medicine, surgical.
- paediatrics, advanced practice nursing, and billing and coding experience .
- Great organizational skills .
- Critical thinkers and the ability to make decisions using clinical background/knowledge .
- Able to work independently .
- Able to collaborate and work with peers to make decisions .
- Knowledge of state and federal regulations
- In-depth Knowledge of ICD-9, CPT, and HCPTS .
All your information will be kept confidential according to EEO guidelines.
