The Medical Review Subject Matter Expert (SME) provides support to the Payment Error Rate Measurement (PERM) Review Contract (RC) team. This position functions as a resource and subject matter expert on problem solving Medical Review issues that would be considered of medium to high degree of complexity.
ESSENTIAL DUTIES AND RESPONSIBILITIES
Essential duties and responsibilities include the following. Other duties may be assigned.
Responsible for the integration of CNI Core Competencies into daily functions, including: commitment to integrity, knowledge / quality of work, supporting financial goals of the company, initiative / motivation, cooperation / relationships, problem analysis / discretion, accomplishing goals through organization, positive oral / written communication skills, leadership abilities, commitment to Affirmative Action, reliability / dependability, flexibility and ownership / accountability of actions taken.
Implements the post payment review processes that are consistent with established industry and department standards and are within the Medical Review Clinician’s professional discipline. Effectively functions in accordance with applicable state, federal laws and regulatory compliance.
Identify issues which can be used to educate nursing/coding staff for the purpose of streamlining and improving processes.
Assist with training for all new nursing and coding staff, serving as the SME for medical review and coding questions from staff. Provides additional instruction as needed to maintain competency of staff.
Assists with obtaining educational materials for the nursing/coding staff and assists with medical review training.
Performs second level Inter-rater Reliability (IRR) and Difference Resolution (DR) reviews as needed.
Reviews medical records to determine if the services identified were medically necessary in accordance with the state policies and federal regulations.
Documents review findings in automated system.
Works collaboratively with the Policy team to research and track new regulations relevant to the reviews.
Keeps Medical Review Manager informed of medical review status.
Performs assigned additional project related responsibilities that are considered small to medium in nature. Ensures project completion which includes educating the Medical Review team. Project assignment is in addition to performing daily Medical Review job responsibilities.
Promotes quality and efficiency in the delivery of post payment review process.
Other duties may be assigned.
Aids in self-development by taking advantage of training made available by the company.
Plans daily activities within the guidelines of company policy, job description and supervisor’s instruction in such a way as to maximize personal output.
Responsible for keeping own immediate work area in a neat and orderly condition to ensure safety of self and coworkers. Will report any unsafe conditions and/or practices to the appropriate supervisor and human resources. Will immediately correct any unsafe conditions to the best of own ability.
Bachelor’s Degree in Nursing and a minimum of three (3) years’ relevant experience practicing as a Registered Nurse, or equivalent combination of education / experience. A minimum of three (3) years’ experience in a supervisory/managerial role in the health insurance industry, a utilization review firm, or other health care claims processing organization involving medical and coding reviews. Extensive experience performing medical review and/or utilization/quality assurance reviews.
JOB SPECIFIC KNOWLEDGE / SKILLS / ABILITIES
Working knowledge of standardized medical review criteria
Working knowledge applying coding guidelines for medical review of Medicaid related services, including Current Procedural Terminology (CPT) codes, International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) codes, and Healthcare Common Procedure Coding System (HCPCS) Codes
Extensive knowledge of state and federal healthcare regulations, policies, coverage guidelines, and reimbursement rules in making clinical determinations as to the medical necessity and appropriateness of services rendered and billed and corresponding payment determinations
Extensive knowledge and proven ability to continually assesses and evaluate clinical compliance with relevant regulations, both at a State and Federal level
Extensive knowledge of the Medicaid and/or CHIP program, particularly the coverage, conditions of payment, and state-specific policy requirements for health care coverage and payment
Exceptional computer skills with advanced proficiency in Microsoft Office (i.e., Word, Excel, Visio, Outlook, etc.)
Excellent organization and time management skills with ability to handle multiple priorities
Exceptional analytical and problem-solving skills with ability to assess business requirements
Ability to collaborate with others for the timely achievement of designated goals and accomplishments
Excellent verbal and written communications skills
Excellent customer service skills
Detail-oriented with ability to proactively identify problems and effectively respond
Ability to use discretion concerning highly sensitive and confidential data and information
Ability to effectively work individually or in a team environment
CERTIFICATES, LICENSES, REGISTRATION
Active Registered Nursing License required
Medical coders shall maintain the required continuing education hours in order to maintain current and proper national certification(s) requirements for this position at no expense to the government. The following are recognized professional certifications:
Registered Health Information Technician (RHIT)
Registered Health Information Administrator (RHIA)
Certified Professional Medical Auditor (CPMA)
Certified Professional Coder (CPC)
Certified Professional Coder, Hospital (CPC-H)
Certified Coding Specialist (CCS)
Certified Coding Specialist – Physician (CCS-P)
Ability to add, subtract, multiply, and divide in all units of measure, using whole numbers, common fractions, and decimals. Ability to compute rate, ratio, and percent and to draw and interpret bar graphs.
Ability to define problems, collect data, establish facts, and draw valid conclusions. Ability to interpret an extensive variety of technical instructions in mathematical or diagram form and deal with several abstract and concrete variables. Ability to solve practical problems and deal with a variety of concrete variables in situations where only limited standardization exists. Ability to interpret a variety of instructions furnished in written, oral, diagram, or schedule form.
Ability to read, analyze, and interpret general business periodicals, professional journals, technical procedures, or governmental regulations. Ability to write reports, business correspondence, and procedure manuals. Ability to effectively present information and respond to questions from groups of managers, clients, customers, and the general public.