Complex Claims Clinical Reviewer REPOSTED

The role involves conducting prepayment and post-payment reviews of inpatient hospital claims, validating the appropriateness of billed ICD-10-CM and ICD-10 PCS codes and MS-DRGs. Utilizing evidence-based criteria supported by current clinical research, the Complex Claims Clinical Reviewer applies clinical expertise and judgment to ensure compliance with medical policy, medical necessity guidelines, and accepted standards of care. Responsibilities include generating Decision Action Notices that provide clear and concise rationales referencing clinical evidence, initiating and verifying claim adjustments, maintaining audit documentation, and preparing statistical data. The reviewer must have a thorough knowledge of federal and state guidelines and regulations related to coding and billing practices, as well as strong oral and written communication skills. Additionally, the role involves identifying, monitoring, and analyzing aberrant patterns of utilization or fraudulent activities by healthcare providers through prepayment claims review, post-payment auditing, and provider record review. Prepayment and post-payment claims queries are completed to identify claims that meet high-dollar and complex care criteria.

Administrative Activities:

The Complex Claims Clinical Reviewer participates in both informal and formal appeal processes, defending decisions before Vaya reconsideration panels, hearing officers, and administrative law judges, and providing litigation testimony as applicable. The role involves working in conjunction with various regulatory bodies to ensure compliance and effectiveness in addressing fraud prevention. Additionally, the Complex Claims Clinical Reviewer proposes new fraud prevention edits for the automated claims and billing system when new fraudulent schemes are identified.

Support Activities:

Perform other duties as assigned, including technical assistance and provider education based upon need, area of expertise, special interests, and availability of resources.

• Adherence to official coding guidelines, coding clinic determinations, and CMS and other regulatory compliance guidelines and mandates. Expert knowledge of DRG & ICD-10 coding required.
• Strong working knowledge of applicable industry-based standards.
• Proficiency in Word, Access, Excel, and other applications.
• Excellent written and verbal communication skills.
• Medicaid experience is a plus.

Bachelor’s Degree in Nursing or a Bachelor’s Degree in Health Information Management is required. In addition 5 to 7 years of working with ICD-10 and MS-DRG, with a broad knowledge of medical claims payment systems, provider billing guidelines, payer reimbursement policies, medical necessity criteria, and coding terminology is required.

Close visual acuity to perform activities such as preparation and analysis of documents; viewing a computer terminal; and extensive reading. Physical activity in this position includes crouching, reaching, walking, talking, hearing and repetitive motion of hands, wrists, and fingers. Sedentary work with lifting requirements up to 10 pounds, sitting for extended periods of time. Mental concentration is required in all aspects of work.