KEY RESPONSIBILITIES:
- Provides technical expertise to Medical Review (MRE) staff including analysis, problem solving, and decision making of complex claim reviews. Identifies medical necessity and /or quality issues for further evaluation. Oversees triage of pended and high dollar claims. Collaborates with external vendors on cases meeting reinsurance thresholds and specific requirements for ASO lines of business.
- Works collaboratively with other departments in providing or seeking claims review and/or clinical guidance. Participates in company committees or work groups as assigned.
- Proactively conducts routine monitoring and identifies areas of potential fraud, waste and/or abuse (FWA). Formulates recommendations based on findings. Suggests opportunities for focused reviews. Works collaboratively with the Compliance Officer and/or Special Investigations (SIU) as needed.
- Coordinates and/or oversees daily activities of the MRE staff. This includes planning, implementing and evaluating MRE goals. It also includes monitoring workload, staff supervision, training, coaching, auditing, teambuilding, performance evaluation and hiring/retaining staff. Provides training for new MRE staff including one-to-one sessions as required for successful staff mastery of job tasks related to claim reviews and special projects.
- Develops and implements operational guidelines for applicable payment policies and/or for other processes pertaining to the medical claim review function. Seeks organizational approval as indicated.
- Monitors the medical claim review tracking database for quality control. Compiles and analyzes data and prepares routine compliance reports.
- Performs other duties as required.
- Excellent analytical and problem-solving skills
- Able to work independently as well as supervise others to meet stringent deadlines
- Strong attention to detail. Highly organized and capable of managing multiple projects.
- Proficient in Microsoft applications.
- Possess strong oral and written communication.
- Ability to work as a team in a high paced environment.
- Successful completion of Health Care Sanctions background check.
- Current active, unrestrictive license to practice as a Registered Nurse (RN) in the State of Oklahoma.
- BSN preferred
- Minimum of five years combined employment in facility/provider health care settings or managed care organization.
- Two years supervisory experience preferred.
- Prefer strong clinical related background and case review experience focused in healthcare fraud, waste and abuse.
- Require experience or familiarity with state and federal regulations governing healthcare coding, billing and claims processing. Recognized healthcare coding certification (CPC, AHIMA, etc.) preferred.
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