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Clinical Reviewer II (Special Investigation Unit)

Company: Centene Coproration
Location: Chesterfield
Posted on: July 12, 2019

Job Description:

Description: Position Purpose: 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

Keywords: Centene Coproration, Chesterfield , Clinical Reviewer II (Special Investigation Unit), Healthcare , Chesterfield, Missouri

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