Care Review Clinician

• 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 .

• RN License Required .

• 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.