Our organization is looking for dynamic individuals who love to learn, thrive on innovation, and are open to exploring new ways to achieve our goals. If this describes you, we want to speak with you. You can help us achieve our vision to lead nationally in innovating equitable whole-person health.
The Care Management Coordinator, Medical Review conducts post service reviews on medical claims and cases to ensure medical criteria has been met in accordance with current Company medical policies and medical management guidelines for inpatient, outpatient, surgical and diagnostic procedures including out of network services. This position is within the Claims Medical Review team.
Responsibilities/Duties
· Reviews provider submission of medical records for specific services that have been processed through system automation and require documentation to determine if additional payment is warranted.
· Reviews specific medical services during the claims adjudication process against medical policies and medical management guidelines to ensure criteria has been met and provides direction to claims processing area.
· Conducts analysis review of post payment claims against current medical policy and medical management guidelines
· Identifies claims/services that require medical records review retrospectively
· Works with Hospitals and Professional providers to obtain medical records to conduct retrospective reviews
· Reviews medical records for identified claims/services to ensure medical criteria based on policies and guidelines have been met
· Identifies and refers cases in which the plan of care/services are not meeting established criteria to the Medical Directors for further evaluation determination
· Collaborates with appropriate areas of the Company including Care Management, Medical Policy, CFID, Appeals, Clinical Vendor Management and Claims Operations.
· Summarizes and tracks all analyses performed and reports to Management
· Identifies and suggests process improvements or potential process efficiencies based on reviews conducted
· Participates in key business area projects
· Assists with review and maintenance of the Claim Medical Review team’s policies, procedures, checklists and documentation as required.
· Performs other related duties as assigned
Knowledge/Skills/Qualifications
· RN license, BSN Preferred
· Minimum 3-5 years' experience with medical criteria reviews
· Strong knowledge of ICD-10, HCPCS and CPT coding/billing
· Claims auditing experience a plus
· Proficiency with Microsoft Word, Outlook, Excel, SharePoint, and Adobe programs. Ability to learn new systems as technology advances.
· Self motivated, highly organized and detailed oriented as well as problem solving, analytical, verbal and written communication skills are required
· Demonstrate the ability to work in a multi-tasking environment