Responsibilities
- Lead prospective claim review audits related to clinical DRG coding compliance and readmissions programs as well as cross-functional high dollar claim review.
- Ensure various payment integrity programs run smoothly and stay compliant with all internal and Medicare guidelines.
- Prepare provider responses to clearly and accurately deliver our review decisions to members and/or providers within regulatory timeframes as established by CMS.
- Identify potential program efficiencies/opportunities and implement procedural responses.
- Continue to analyze existing policies to ensure accuracy and proper execution.
- Collaborate with teams across Clover to ensure provider understanding of Payment Integrity recommendations and be prepared to support those recommendations when necessary.
- Act as Subject Matter Expert to counsel other team members across Clover on clinical coding guidelines: digest complex concepts and regulations and communicate them effectively to different stakeholders, including senior-level leadership.
- Train other members of the team to take on additional responsibilities and help prioritize work functions.
- Research and respond to external auditor concerns/questions regarding the completeness and accuracy of data creation and integration.
- Incorporate cross-functional perspectives and business needs in solving complex problems.
- Communicate effectively both internally and externally to ensure accurate claims adjudication and proper provider notification.
Requirements
- You hold a CCS or CIC certification (required).
- You have current or previous nursing/firsthand clinical experience or CDI certification (required).
- You have a deep understanding of CMS rules and regulations.
Nice to Have
- You have previous experience in the insurance industry.
- You are technologically savvy with strong computer skills in Access, Excel, Visio, and PowerPoint.
- Knowledge of statistical methods used in the evaluation of healthcare claims data and SQL a plus.
