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Clinical Reviewer II (Special Investigation Unit - Certified Coder)
Austin , TX 73301
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Position Purpose:Audit medical records to identify inappropriate billing practices and determine medical necessity through extensive review of claims data, medical records, corporate policies, state/federal policies, and the interpretation of practice standards,
- Perform complex retrospective and prepayment reviews of medical records to identify potential abuse and fraud and inappropriate billing practices. Responsible for second level appeals reviews
- Investigate, analyze, and identify provider billing patterns to recommend payment based on medical records, claim history, billing codes, regulatory and state guidelines, and policies
- Prepare summary of findings and recommend next steps for providers
- Identify preventative measures and recommend changes to internal policies and procedures and/or provider practices to prevent future fraudulent and erroneous practices
- Consult investigators to identify abuse and fraud by utilizing clinical and coding expertise to analyze patterns in billing activities
- Perform onsite audits in conjunction with investigators and/or managers. Review providers claims history, licensure, and specialty. Assess providers by interviewing staff, examining the facility and equipment, and reviewing medical records
- Provide instructions to the claims department for prepayment reviews
- Assist SIU Clinical Supervisor/Manager as needed with training new hires, answering questions from Clinical Reviewer I employees, auditing work of junior-level employees, assisting with provider education, and answering questions from investigators
- Associates degree in Nursing, Counseling, or related field.
- Coding Certification and 4+ years of medical coding experience; or RN, LPC, LCSW, LMHC, PT, OT or ST license and 4+ years of related clinical experience in the field of obtained license.
- Experience in provider education preferred. Experience in a managed care organization preferred. Experience in medical record auditing preferred.
- Coding certification from an accredited organization (American Academy of Professional Coders or American Health Information Management Association), RN, LPC, LCSW, LMHC, PT, OT, or ST.