This position not only requires the fundamental skillset to perform Payment Integrity Clinical Capability Reviews, but also requires the candidate to identify and facilitate resolution of issues related to these processes. This includes, but is not limited to, analyzing skilled and facility provider claims data, determining appropriateness of code submission, analyzing claim rejection codes and the proper action to complete the claim review with the goal of proper and timely payment to provider and member satisfaction. The Sr. Payment Integrity Clinician is responsible for the training of new staff who will execute effective Payment Integrity Clinical Capability strategies on a pre-payment and retrospective claims review basis. The Payment Integrity claims review process includes a review of medical documentation, itemized bills, and claims data to assure appropriate level of payment and resource utilization. It is also used to identify issues which can be used for education of network providers, identification and resolution of quality issues and inappropriate claim submission, which the candidate may be involved in. The Sr. Payment Integrity Clinician is expected to utilize specialized skills and knowledge to achieve successful and measurable outcomes. The Sr. Payment Integrity Clinician monitors and analyzes the delivery of health care services in accordance with claims submitted, and analyzes qualitative and quantitative data in developing strategies to improve provider performance and member satisfaction. The Sr.
Payment Integrity Clinician is expected to identify potential discrepancies in provider billing practices and intervene for resolution and education or if necessary involve Special Investigation Unit or the Utilization Management area.
II. ESSENTIAL RESPONSIBILITIES:
1. Acts as a resource and subject matter expert to colleagues with less experience on a frequent basis to problem solve through Payment Integrity Clinical Capability issues that would be considered of medium to high degree of complexity.
2. Identify issues which can be used to educate professional and facility providers and vendors for the purpose of streamlining and improving processes. Develops and sustains positive working relationships with internal and external customers.
3. Other duties as assigned. Including, but not limited to additional project related responsibilities on a frequent basis that are considered small to medium in nature. Drive execution and maintece of Payment Integrity Clinical Capability workflow. Expectation is to drive the assigned project to completion which would include educating the Payment Integrity team. Project assignment is in addition to performing daily Payment Integrity job responsibilities.
4.
Implements the pre-payment and retrospective review processes that are consistent with established industry and corporate standards and are within the Payment Integrity Clinical Capabilities professional discipline. Effectively functions in accordance with applicable state, federal laws and regulatory compliance. Implements all reviews according to accepted and established coding criteria, as well as other approved guidelines, payment and medical policies. Promotes quality and efficiency in the delivery of review services.
5. Ability to visualize, articulate and solve complex problems representative of a broad range of service and claim scenarios.
6. Respects the members right to privacy, sharing only information relevant to the members care and within the framework of applicable laws. Practices within the scope of ethical principles.