SR Clinical Consultant Audit/Recovery Payment Integrity

Explore opportunities with WellMed, part of the Optum family of businesses. We believe all patients are entitled to the highest level of medical care. Here, you will be part of a team who shares your passion for helping people achieve improved health outcomes. Explore rewarding opportunities for physicians, clinical staff and non-patient-facing roles. Join us and discover the meaning behind Caring. Connecting. Growing together.  

The Sr. Clinical Consultant - Payment Integrity position is responsible for determining medical appropriateness of inpatient and outpatient services following evaluation of medical documentation, and published CMS, Coding and other industry criteria. This position will provide direction and guidance to Medical Coding Analysts, as well as cross-functional team members within Payment Integrity and Claims.  Responsible for communication with medical professionals and written education material to support improved documentation and correct coding in future.

You'll enjoy the flexibility to work remotely * from anywhere within the U.S. as you take on some tough challenges.

Primary Responsibilities:

• Investigate, review, and provide clinical and / or coding expertise in review of post - service, pre- payment or post payment claims, which requires interpretation of state and federal mandates, billing practices / patterns, applicable benefit language, medical and reimbursement policies, medical necessity, coding requirements and consideration of relevant clinical information on claims with overt billing patterns and make pay / deny or payment recommendation decisions based on findings; this could include Medical Director / physician consultations and working independently while making their decisions
• Conduct extensive audits on a project basis: generate response letter for review by medical director(s).  Monitor action plan as a result of the audit - responsible for tracking and documenting the whole process
• Positions in this function perform comprehensive research and identify billing abnormalities, questionable billing practices, and/or irregularities
• Investigate, research, and analyze claims data applying knowledge of medical or pharmacy policy to determine details of fraudulent or abusive billing activity
• Work with Payment Integrity Analytics to determine audit sample and if a statistical extrapolation is possible what is that audit size
• Conduct audits of provider records, and claims submissions to ensure appropriateness of billing practices and application of medical policy
• Identify and document fraudulent or erroneous activity during an audit
• Determine actual overpayment that may have occurred. Generates written notice to providers on audit findings and works with claims and legal to obtain overpayment
• Participate in case review and medical determination conference/consults
• Conduct reviews for medical necessity and determination of correct coding
• Facilitate improvement in overall quality, completeness, and accuracy of medical record documentation
• Coordinate education related to compliance, coding, and clinical documentation for payment integrity issues within the healthcare organization
• Act as a consultant to claims coding professionals when additional information or documentation is needed to assign coded data
• Take ownership of the total work process and provides constructive information to minimize problems and increase customer satisfaction
• FWAE detection and identification of aberrant behavior for providers and facilities
• Identify updated clinical analytics opportunities and participate in projects as necessary by client / other departments
• Maintain and manage case review assignments
• Ensure issues are identified, tracked, reported and resolved
• Develop relevant training programs, policies and procedures, and resources that enable the claims and benefit load staff to process and perform job duties with accurate and timely information
• Review and edit requirements, specifications, business processes and recommendations related to proposed solutions and write business rules to support benefit and claims functions
• Work directly with management teams on quality results, trending analysis and needed process improvement
• Escalate issues to project team and management for support and / or guidance
• Keep abreast of current Medicare guidelines and Regulations and compliance standards by reviewing