12 days old

Special Investigations Unit Clinical Reviewer

EmblemHealth
New York, NY 10007
  • Job Code
    191B0
Assists the SIU investigators with pre-pay and post pay reviews of medical records on suspect providers. Provides a professional opinion regarding medical necessity inclusive of claims edits associated with utilization management and/or authorized services. Provides an analytical decision about services rendered according to the department guidelines and members benefits. Performs clinical review of SIU clinical cases to include appeals, retrospective reviews and claims edits.

Responsibilities:

  • Assist SIU investigators with pre-pay and post-pay reviews of medical records on suspect providers.
  • Review cases referred for medical necessity and correct coding guidelines, utilizing InterQual Criteria, CMS Guidelines, medical and administrative policies to evaluate and make clinical/coding decisions as appropriate.
  • Prepare and present clinical detail to the Medical Director for final case determination in accordance with regulation and department policy.
  • Set up medical necessity case denials in MaxMC. Prepare and send out IAD letters for lack of medical necessity, as needed.
  • Ensure utilization timeframes are met according to regulatory guidelines (i.e., initial determination decisions, adverse determination notification to providers and members).
  • Effectively communicate verbally and in writing all decisions in a timely and professional manner.
  • Regular attendance is an essential function of the job. Perform other duties as assigned or required.

Qualifications:

  • Must be a Registered Nurse or LPN licensed with at least 3 years of clinical experience and an active, unrestricted license or certification
  • Bachelor of Science in Nursing (BSN) degree preferred
  • Certified Professional Coder (CPC) preferred
  • Prior managed care experience preferred, including in-depth knowledge of Medicare, Medicaid and Commercial Product Lines
  • Ability to proficiently read and interpret medical records
  • Ability to apply clinical criteria and guidelines
  • Knowledge of ICD-9/10 and CPT codes
  • Strong clinical knowledge and coding skills
  • Strong organizational skills
  • Ability to perform independently and prioritize projects/assignments
  • Ability to meet deadlines
  • Excellent verbal and written communication skills

Additional Information

  • Requisition ID: 191B0






Posted: 2019-10-31 Expires: 2019-11-29
Sponsored by:
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Sponsored by:
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Special Investigations Unit Clinical Reviewer

EmblemHealth
New York, NY 10007

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