Clinical Reviewer III, Licensed/Remote (Louisiana)
Baton Rouge, LA jobs
Conducts and oversees treatment record and case management record reviews. Trends and analyzes findings for internal and external reporting.
Reviews charts and analyzes clinical record documentation.
Conducts ongoing activities which monitor established quality of care standards in the participating provider network and for other clinical staff.
Collects, analyzes and prepares clinical record information for projects related to assessing the efficiency, effectiveness and quality of the delivery of managed care services.
Prepares monthly performance reports.
Assists in the planning and implementation of activities to improve delivery of services and quality of care including the development and coordination of in-service education programs for providers and other clinical staff.
Provides training, interpretation and support for QI Clinical Reviewer staff.
Audits and validates internal audit results and/or corrective action plans.
The job duties listed above are representative and not intended to be all-inclusive of what may be expected of an employee assigned to this job. A leader may assign additional or other duties which would align with the intent of this job, without revision to the job description.
Other Job Requirements
Responsibilities
RN/BSN or clinical credentials in a behavioral health field. If not an RN, must hold Masters or Doctoral Degree and be a licensed behavioral health professional.
Good organization, time management and verbal and written communication skills.
Knowledge of utilization management procedures, Medicaid benefits, community resources and providers.
knowledge and experience in diverse patient care settings including inpatient care.
Ability to function independently and as a team member.
Knowledge of ICD and DSM IV coding or most current edition.
Ability to analyze specific utilization problems and creatively plan and implement solutions.
Ability to use computer systems.
7 or more years of experience post degree in a clinical, psychiatric and/or substance abuse health care setting.
Also requires minimum of 4 years of experience conducting utilization management according to medical necessity criteria.
General Job Information
Title
Clinical Reviewer III, Licensed/Remote (Louisiana)
Grade
26
Work Experience - Required
Clinical, Utilization Management
Work Experience - Preferred
Education - Required
Bachelor's - Nursing, Master's - Social Work
Education - Preferred
License and Certifications - Required
LCSW - Licensed Clinical Social Worker - Care MgmtCare Mgmt, LISW - Licensed Independent Social Worker - Care MgmtCare Mgmt, LMFT - Licensed Marital and Family Therapist - Care MgmtCare Mgmt, LMSW - Licensed Master Social Worker - Care MgmtCare Mgmt, LPCC - Licensed Professional Clinical Counselor - Care MgmtCare Mgmt, RN - Registered Nurse, State and/or Compact State Licensure - Care MgmtCare Mgmt
License and Certifications - Preferred
Salary Range
Salary Minimum:
$70,715
Salary Maximum:
$113,145
This information reflects the anticipated base salary range for this position based on current national data. Minimums and maximums may vary based on location. Actual pay will be adjusted based on an individual's skills, experience, education, and other job-related factors permitted by law.
This position may be eligible for short-term incentives as well as a comprehensive benefits package. Magellan offers a broad range of health, life, voluntary and other benefits and perks that enhance your physical, mental, emotional and financial wellbeing.
Magellan Health, Inc. is proud to be an Equal Opportunity Employer and a Tobacco-free workplace. EOE/M/F/Vet/Disabled.
Every employee must understand, comply with and attest to the security responsibilities and security controls unique to their position; and comply with all applicable legal, regulatory, and contractual requirements and internal policies and procedures.
Auto-ApplyClaims Reviewer Clerk
Nipomo, CA jobs
Job Title: Claims Reviewer Clerk Department: 340B Reports To: Director of 340B Program FLSA Status: Non-Exempt Wage Range that the Company Expects to Pay: $26.00 - $28.67 per hour Under the supervision of the Director of 340B Program, the Claims Reviewer clerk shall perform chart reviews to locate chart notes, consultations, medications and referral orders to support 340B claims as well as other duties. The Claims Reviewer clerk will work with team members, clinic staff, and physicians to ensure all requirements are met.
It is the primary purpose of CHCCC to provide the highest quality of total care possible to the patient population it serves. Such a level of quality depends ultimately on the staff's desire and ability to work together, individually, and as a team. The employee is expected to be professional, punctual, maintain regular attendance, cooperative, motivated, and organized at all times.
ESSENTIAL DUTIES AND RESPONSIBILITIES include the following. Additional duties may be assigned with or without prior notice.
Uses 340B reports to identify patient charts that require review for chart notes, consultations, medication documentation and referral orders.
Performs chart review, identifies presence or absence of required elements.
Works with Specialty offices or Referral Department to retrieve the missing consultation documentation.
Contacts pharmacies to obtain a copy of the prescription when the consultation documentation does not include medication referenced in 340B claims report.
Uses pharmacology references to determine generic from brand name prescription drugs.
Works with office staff, medication case managers and physicians to ensure medication reconciliation is completed to reflect medications from 340B claims report.
Works with office staff and physicians to ensure referral order is in chart for patients seen by and receiving prescription drugs from consulting specialist.
Faxes consultations and prescription slips to Athena for scanning into patients EMR.
Work with 340B team to verify 340B claims reports.
Review invoice pricing, prepare and maintain accounting documents and records.
Demonstrates professionalism and provides quality customer service using AIDET Standards.
Ability to work with high volume of patients, internal/external customers, and deal with frequent changes, delay or unexpected events.
Demonstrates adherence to and observes all safety policies and procedures.
Demonstrates knowledge of domestic violence, child and dependent abuse protocols.
Demonstrates cultural sensitivity and competence with patients.
Maintains and adheres to HIPAA, employee confidentiality, and privileged communications (patient, employee, and corporation).
Excellent command of Microsoft Excel
Must be able to meet deadlines
Perform other duties as assigned
SUPERVISORY RESPONSIBILITIES
This job has no supervisory responsibilities.
QUALIFICATIONS
To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
EDUCATION and/or EXPERIENCE
High school diploma or GED required. Graduation from an accredited school in Medical Assisting or a certified or registered medical assistant (CMA/RMA), or other relevant medical experience.
LANGUAGE SKILLS
Ability to read, analyze, and interpret documents such as safety rules, operating and maintenance instructions, policy and procedure manuals. Ability to respond effectively to the most sensitive inquires or complaints. Ability to write routine reports and correspondence. Ability to speak effectively before groups of patients or employees of organization.
MATHEMATICAL SKILLS
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.
REASONING ABILITY
Ability to apply sound judgment in understanding to carry out instructions in written or oral form. Ability to make appropriate job decisions following standard office policies and past precedents.
COMPUTER SKILLS
Experience with word processing, spreadsheets, email, and keyboarding required. Microsoft Office including Microsoft Word and Excel, and Google Suite skills required. Working knowledge of EHR preferred.
CERTIFICATES, LICENSES, REGISTRATIONS
Possession of current, valid, unrestricted California Driver's License (Class C) required.
OTHER REQUIREMENTS
Basic accounting skills preferred
Required to pass a criminal history background check and drug screen upon hire.
Annual health examination; annual Tuberculosis skin test clearance or chest x-ray; proof of immunity to MMR, Varicella, and Hepatitis B; proof of Tdap vaccine; during current flu season, must provide proof of influenza vaccine or a signed declination form. If declined, a flu mask is mandatory during flu season.
PHYSICAL DEMANDS
The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
While performing the duties of this job, the employee is regularly required to use hands to finger, handle, or feel; reach with hands and arms; and talk or hear. The employee occasionally is required to sit. The employee is occasionally required to stand and walk for extended periods of time. The employee may occasionally lift and/or move up to 10 pounds of supplies. Specific vision abilities required by this job include close vision, distance vision, color vision, peripheral vision, depth perception, and ability to adjust focus.
WORK ENVIRONMENT
The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
While performing the duties of this job, the employee is occasionally exposed to moving mechanical parts. The employee is occasionally exposed to risk of electrical shock. The noise level in the work environment is moderate (i.e. office setting with computers, phones, and printers). Must be able to work in a fast-paced environment.
Must be willing to have a flexible work schedule that may include evenings/weekends, and travel as needed.
The above statements are intended to describe the general nature and level of work being performed by individuals assigned to this position. They are not intended to be an exhaustive list of all duties, responsibilities, and skills required of personnel so classified.
Sr, Research Interviewer (ETS) | Temporary
Atlanta, GA jobs
**Discover Your Career at Emory University** Emory University is a leading research university that fosters excellence and attracts world-class talent to innovate today and prepare leaders for the future. We welcome candidates who can contribute to the excellence of our academic community.
**Description**
KEY RESPONSIBILITIES:
+ Recruits, screens, identifies, contacts, and interviews participants to obtain data for assigned research projects.
+ Interviews may be conducted in person, in a clinical setting, the subject's residence, or by telephone.
+ Coordinates the data collection process.
+ May abstract data from the participant's medical record.
+ Schedules appointments, obtains consent forms, explains the study to the participant and collects data.
+ May observe participants and record results of observation through written documentation or video recording.
+ Edits completed questionnaires for completeness, legibility and accuracy.
+ Follows up with participants to obtain missing data or clarify existing data.
+ Designs forms, worksheets and study questionnaires.
+ May code and enter data into a database.
+ Compiles data and produces reports to be used for analysis of research findings.
+ May monitor blood pressure and heart rate and may take vital signs and height/weight measurements.
+ May collect blood, saliva, or urine samples from participants and prepare them for laboratory testing.
+ Provides direction to others engaged in the interviewing process.
+ Maintains required record-keeping.
+ Performs related responsibilities as required.
MINIMUM QUALIFICATIONS:
+ A high school diploma or equivalent.
+ Two years of administrative support, customer service or other related experience which includes one year of interviewing experience.
+ Data entry experience.
+ Positions that require drawing blood require completion of a phlebotomy training program.
NOTE: Position tasks are required to be performed in-person at an Emory University location; working remote is not an option. Emory reserves the right to change this status with notice to employee
**Additional Details**
Emory is an equal opportunity employer, and qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, disability, protected veteran status or other characteristics protected by state or federal law. Emory University does not discriminate in admissions, educational programs, or employment, including recruitment, hiring, promotions, transfers, discipline, terminations, wage and salary administration, benefits, and training. Students, faculty, and staff are assured of participation in university programs and in the use of facilities without such discrimination. Emory University complies with Section 503 of the Rehabilitation Act of 1973, the Vietnam Era Veteran's Readjustment Assistance Act, and applicable executive orders, federal and state regulations regarding nondiscrimination, equal opportunity, and affirmative action (for protected veterans and individuals with disabilities). Inquiries regarding this policy should be directed to the Emory University Department of Equity and Civil Rights Compliance, 201 Dowman Drive, Administration Building, Atlanta, GA 30322. Telephone: ************ (V) | ************ (TDD).
Emory University is committed to ensuring equal access and providing reasonable accommodations to qualified individuals with disabilities upon request. To request this document in an alternate format or to seek a reasonable accommodation, please contact the Department of Accessibility Services at accessibility@emory.edu or call ************ (Voice) | ************ (TDD). We kindly ask that requests be made at least seven business days in advance to allow adequate time for coordination.
**Connect With Us!**
Connect with us for general consideration!
**Job Number** _156988_
**Job Type** _Temporary Full-Time_
**Division** _School Of Medicine_
**Department** _SOM: Medicine: Cardiology_
**Job Category** _Clinical Research_
**Campus Location (For Posting) : Location** _US-GA-Atlanta_
**_Location : Name_** _HSRB II (Health Sciences Research Building II)_
**Remote Work Classification** _No Remote_
**Health and Safety Information** _Position involves clinical patient contact, Working with human blood, body fluids, tissues, or other potentially infectious materials_
Data Reviewer, Quality Control
Tustin, CA jobs
Looking to join a passionate team dedicated to developing and manufacturing life-saving biopharmaceuticals? Avid Bioservices is a leading clinical and commercial biologics CDMO focused on creating innovative solutions to meet the needs of our clients and improve patient outcomes.
Your Role:
The Data Reviewer, Quality Control's main responsibility will be to review Quality Control analytical data.
In this role you will:
* Conduct a comprehensive and critical evaluation on QC data in Empower and SoftMax Pro software including but not limited to contents, results, data accuracy, and scientific relevance, format and adherence to cGMPs.
* Perform a thorough review of raw data, including electronic raw data and documentations to ensure compliance with applicable specifications and/or protocols.
* Conduct GMP review of laboratory notebooks, logbooks, and associate forms.
* Conduct GMP review of electronic raw data to ensure compliance with data integrity policies.
* Support OOS/OOT investigations.
* Support internal and external audit.
* Support QC method validation review, as needed.
* Perform review of procedural and method revisions, where necessary.
* Perform other duties as assigned to support Quality activities.
Minimum Qualifications:
* Bachelor's degree, preferably in a life sciences field (such as biology, microbiology, biochemistry, chemistry).
* 4+ years' work experience in a GMP/biopharmaceutical/pharmaceutical manufacturing environment.
* Experience with Empower and SoftMax Pro software.
* Knowledge of cGMPs, pharmacopeia and compendial requirements.
* Experience in and knowledge of 21 CFR data integrity requirements.
* Familiarity with analytical testing methods and validation including laboratory instrumentation.
* Strong verbal and written communication skills.
* Familiarity with laboratory computerized systems such as Empower and LIMS.
* Proficient with Microsoft applications.
Position Type/Expected Hours of Work:
This role is a full-time position. Days and hours of work are Monday through Friday, 8:00 a.m. to 5 p.m. unless otherwise stated by Supervisor. Must be available to work holidays, weekends, or extended hours if needed.
Compensation:
We offer competitive compensation packages for this role, including a base salary, performance-based bonuses, and comprehensive benefits such as health, dental, and vision insurance, 401(k) matching, and paid time off.
The compensation range for this role is $26.73-$35.62 hourly, depending on experience and qualifications. Additionally, we offer opportunities for career growth and development as well as a supportive and inclusive work environment.
Who you are:
* You have a "bring it on!" team player approach and an unshakable positive attitude, always ready to tackle anything that comes your way.
* Your written and verbal skills are out of this world, and you communicate with clarity and confidence.
* You have exceptional multitasking skills and an unparalleled attention to detail that ensure the smooth running of everything.
* You are a master at building relationships, capable of establishing connections with anyone, be it team members, clients, vendors, or suppliers.
Physical Demands & Work Environment:
In this dynamic role, expect a blend of regular activities like sitting, standing, and walking, with occasional physically engaging tasks such as lifting objects up to 20 pounds. The work environment might expose you to electrical shocks, toxic chemicals, vibrations, or loud noise levels occasionally. However, reasonable accommodations are available to enable individuals with different abilities to perform effectively, ensuring a supportive and adaptable work setting. Your visual acuity, including close, distance, and color vision, will be essential in navigating through the diverse day-to-day demands of this position.
Auto-ApplyClaims Reviewer Clerk
Nipomo, CA jobs
Job Title: Claims Reviewer Clerk
Department: 340B
Reports To: Director of 340B Program
FLSA Status: Non-Exempt
Wage Range that the Company Expects to Pay: $26.00 - $28.67 per hour
Under the supervision of the Director of 340B Program, the Claims Reviewer clerk shall perform chart reviews to locate chart notes, consultations, medications and referral orders to support 340B claims as well as other duties. The Claims Reviewer clerk will work with team members, clinic staff, and physicians to ensure all requirements are met.
It is the primary purpose of CHCCC to provide the highest quality of total care possible to the patient population it serves. Such a level of quality depends ultimately on the staff's desire and ability to work together, individually, and as a team. The employee is expected to be professional, punctual, maintain regular attendance, cooperative, motivated, and organized at all times.
ESSENTIAL DUTIES AND RESPONSIBILITIES include the following. Additional duties may be assigned with or without prior notice.
Uses 340B reports to identify patient charts that require review for chart notes, consultations, medication documentation and referral orders.
Performs chart review, identifies presence or absence of required elements.
Works with Specialty offices or Referral Department to retrieve the missing consultation documentation.
Contacts pharmacies to obtain a copy of the prescription when the consultation documentation does not include medication referenced in 340B claims report.
Uses pharmacology references to determine generic from brand name prescription drugs.
Works with office staff, medication case managers and physicians to ensure medication reconciliation is completed to reflect medications from 340B claims report.
Works with office staff and physicians to ensure referral order is in chart for patients seen by and receiving prescription drugs from consulting specialist.
Faxes consultations and prescription slips to Athena for scanning into patient s EMR.
Work with 340B team to verify 340B claims reports.
Review invoice pricing, prepare and maintain accounting documents and records.
Demonstrates professionalism and provides quality customer service using AIDET Standards.
Ability to work with high volume of patients, internal/external customers, and deal with frequent changes, delay or unexpected events.
Demonstrates adherence to and observes all safety policies and procedures.
Demonstrates knowledge of domestic violence, child and dependent abuse protocols.
Demonstrates cultural sensitivity and competence with patients.
Maintains and adheres to HIPAA, employee confidentiality, and privileged communications (patient, employee, and corporation).
Excellent command of Microsoft Excel
Must be able to meet deadlines
Perform other duties as assigned
SUPERVISORY RESPONSIBILITIES
This job has no supervisory responsibilities.
QUALIFICATIONS
To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
EDUCATION and/or EXPERIENCE
High school diploma or GED required. Graduation from an accredited school in Medical Assisting or a certified or registered medical assistant (CMA/RMA), or other relevant medical experience.
LANGUAGE SKILLS
Ability to read, analyze, and interpret documents such as safety rules, operating and maintenance instructions, policy and procedure manuals. Ability to respond effectively to the most sensitive inquires or complaints. Ability to write routine reports and correspondence. Ability to speak effectively before groups of patients or employees of organization.
MATHEMATICAL SKILLS
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.
REASONING ABILITY
Ability to apply sound judgment in understanding to carry out instructions in written or oral form. Ability to make appropriate job decisions following standard office policies and past precedents.
COMPUTER SKILLS
Experience with word processing, spreadsheets, email, and keyboarding required. Microsoft Office including Microsoft Word and Excel, and Google Suite skills required. Working knowledge of EHR preferred.
CERTIFICATES, LICENSES, REGISTRATIONS
Possession of current, valid, unrestricted California Driver's License (Class C) required.
OTHER REQUIREMENTS
Basic accounting skills preferred
Required to pass a criminal history background check and drug screen upon hire.
Annual health examination; annual Tuberculosis skin test clearance or chest x-ray; proof of immunity to MMR, Varicella, and Hepatitis B; proof of Tdap vaccine; during current flu season, must provide proof of influenza vaccine or a signed declination form. If declined, a flu mask is mandatory during flu season.
PHYSICAL DEMANDS
The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
While performing the duties of this job, the employee is regularly required to use hands to finger, handle, or feel; reach with hands and arms; and talk or hear. The employee occasionally is required to sit. The employee is occasionally required to stand and walk for extended periods of time. The employee may occasionally lift and/or move up to 10 pounds of supplies. Specific vision abilities required by this job include close vision, distance vision, color vision, peripheral vision, depth perception, and ability to adjust focus.
WORK ENVIRONMENT
The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
While performing the duties of this job, the employee is occasionally exposed to moving mechanical parts. The employee is occasionally exposed to risk of electrical shock. The noise level in the work environment is moderate (i.e. office setting with computers, phones, and printers). Must be able to work in a fast-paced environment.
Must be willing to have a flexible work schedule that may include evenings/weekends, and travel as needed.
The above statements are intended to describe the general nature and level of work being performed by individuals assigned to this position. They are not intended to be an exhaustive list of all duties, responsibilities, and skills required of personnel so classified.
Data Reviewer, Quality Control
Tustin, CA jobs
Description Looking to join a passionate team dedicated to developing and manufacturing life-saving biopharmaceuticals? Avid Bioservices is a leading clinical and commercial biologics CDMO focused on creating innovative solutions to meet the needs of our clients and improve patient outcomes. Your Role: The Data Reviewer, Quality Control's main responsibility will be to review Quality Control analytical data. In this role you will:
Conduct a comprehensive and critical evaluation on QC data in Empower and SoftMax Pro software including but not limited to contents, results, data accuracy, and scientific relevance, format and adherence to cGMPs.
Perform a thorough review of raw data, including electronic raw data and documentations to ensure compliance with applicable specifications and/or protocols.
Conduct GMP review of laboratory notebooks, logbooks, and associate forms.
Conduct GMP review of electronic raw data to ensure compliance with data integrity policies.
Support OOS/OOT investigations.
Support internal and external audit.
Support QC method validation review, as needed.
Perform review of procedural and method revisions, where necessary.
Perform other duties as assigned to support Quality activities.
Minimum Qualifications:
Bachelor's degree, preferably in a life sciences field (such as biology, microbiology, biochemistry, chemistry).
4+ years' work experience in a GMP/biopharmaceutical/pharmaceutical manufacturing environment.
Experience with Empower and SoftMax Pro software.
Knowledge of cGMPs, pharmacopeia and compendial requirements.
Experience in and knowledge of 21 CFR data integrity requirements.
Familiarity with analytical testing methods and validation including laboratory instrumentation.
Strong verbal and written communication skills.
Familiarity with laboratory computerized systems such as Empower and LIMS.
Proficient with Microsoft applications.
Position Type/Expected Hours of Work: This role is a full-time position. Days and hours of work are Monday through Friday, 8:00 a.m. to 5 p.m. unless otherwise stated by Supervisor. Must be available to work holidays, weekends, or extended hours if needed. Compensation: We offer competitive compensation packages for this role, including a base salary, performance-based bonuses, and comprehensive benefits such as health, dental, and vision insurance, 401(k) matching, and paid time off. The compensation range for this role is $26.73-$35.62 hourly, depending on experience and qualifications. Additionally, we offer opportunities for career growth and development as well as a supportive and inclusive work environment. Who you are:
You have a "bring it on!" team player approach and an unshakable positive attitude, always ready to tackle anything that comes your way.
Your written and verbal skills are out of this world, and you communicate with clarity and confidence.
You have exceptional multitasking skills and an unparalleled attention to detail that ensure the smooth running of everything.
You are a master at building relationships, capable of establishing connections with anyone, be it team members, clients, vendors, or suppliers.
Physical Demands & Work Environment: In this dynamic role, expect a blend of regular activities like sitting, standing, and walking, with occasional physically engaging tasks such as lifting objects up to 20 pounds. The work environment might expose you to electrical shocks, toxic chemicals, vibrations, or loud noise levels occasionally. However, reasonable accommodations are available to enable individuals with different abilities to perform effectively, ensuring a supportive and adaptable work setting. Your visual acuity, including close, distance, and color vision, will be essential in navigating through the diverse day-to-day demands of this position.
Auto-ApplySpecial Investigations Unit Medical Reviewer (Hybrid Work Schedule)
Rancho Cucamonga, CA jobs
What you can expect!
Find joy in serving others with IEHP! We welcome you to join us in “healing and inspiring the human spirit” and to pivot from a “job” opportunity to an authentic experience!
Under general supervision, the Special Investigations Unit Medical Reviewer (SIU Medical Reviewer) performs reviews of medical records and healthcare claims to substantiate or refute the accuracy and compliance with federal and state regulations and contractual requirements of codes billed to identify coding errors and billing discrepancies in relation to incidents of suspected healthcare fraud, waste, and abuse (FWA) reported to IEHP's Compliance Special Investigations Unit (SIU).
Commitment to Quality: The IEHP Team is committed to incorporate IEHP's Quality Program goals including, but not limited to, HEDIS, CAHPS, and NCQA Accreditation.
Additional Benefits
Perks
IEHP is not only committed to healing and inspiring the human spirit of our Members, but we also aim to match our team members with the same energy by providing prime benefits and more.
Competitive salary
Hybrid schedule
State of the art fitness center on-site
Medical Insurance with Dental and Vision
Life, short-term, and long-term disability options
Career advancement opportunities and professional development
Wellness programs that promote a healthy work-life balance
Flexible Spending Account - Health Care/Childcare
CalPERS retirement
457(b) option with a contribution match
Paid life insurance for employees
Pet care insurance
Key Responsibilities
Perform reviews of medical records and healthcare claims, determining the accuracy of codes billed and compliance with appropriate policies, procedures, and regulations.
Understand, interpret, analyze, and make determinations concerning use of CDT, CPT, ICD, DRG, REV and HCPCS coding as it relates to potential healthcare FWA schemes.
Conduct research relevant to issues under review.
Prepare and submit detailed reports with the results of medical reviews, including corrective action recommendations to investigators. Recommendations may include determinations to deny, recover on overpaid claims, risk mitigation strategies, create internal process improvements or provide education to subjects under review.
Apply knowledge of healthcare coding conventions, policies, and other areas of vulnerability.
Support/participate in provider calls and reinforce medical review findings and provider education.
Presents findings to leadership, regulators and law enforcement and assist in legal proceedings, as appropriate.
Maintain knowledge of new and relevant regulations, standards, and coding guidelines.
Identify inefficiencies in policies or processes and recommend improvements.
Maintain confidentiality and discretion in all investigative activities.
Support special projects and other duties as assigned.
Qualifications
Education & Requirements
A minimum of two (2) years of experience performing medical reviews of medical records and claims in a healthcare setting
Bachelor's degree in Medical Billing/Medical Coding, Nursing, Healthcare Administration, or related field from an accredited institution required
In lieu of the required degree, a minimum of four (4) years of additional relevant work experience is required for this position
This experience is in addition to the minimum years listed in the Experience Requirements above
Certified Professional Coder (CPC), Certified Professional Medical Auditor (CPMA), or Certified Coding Specialist (CCS) required
One of the following licenses preferred:
Possession of an active, unrestricted, and unencumbered Vocational Nurse (LVN) license issued by the California Board of Vocational Nursing and Psychiatric Technicians
Possession of an active, unrestricted, and unencumbered Registered Nurse (RN) license issued by the California BRN
Key Qualifications
Must have a valid California Driver's license
Strong understanding of medical coding, billing practices, and healthcare regulations
Thorough understanding of ICD, CPT, HCPCS, DRG, revenue codes, NDC's and other guidelines and general understanding of investigative processes within a healthcare environment are required
Knowledge of Medi-Cal and Medicare rules and regulations, and managed care in California is preferred
Strong verbal and written communication, interpersonal skills, critical problem-solving skills, and attention to detail
Above average proficiency in the use of technology applications, particularly Excel, Word, and others as necessary
Detail-oriented with strong organizational and time management abilities. Ability to articulate medical review findings clearly and thoroughly
Conduct research in support of medical reviews and make determinations on claims with a high level of accuracy
Demonstrated ability to interpret and analyze healthcare data and records
Adapt to different technology software and platforms, including anti-fraud solutions
Ability to work independently and collaboratively with a team
Start your journey towards a thriving future with IEHP and apply TODAY!
Work Model Location
This position is on a hybrid work schedule. (Mon & Fri - remote, Tues - Thurs onsite in Rancho Cucamonga, CA.)
Pay Range USD $71,572.80 - USD $93,038.40 /Yr.
Auto-ApplyCoding Quality Reviewer II - CPC CCS - Surgical Abstract Coding Experience Required - Remote
Remote
Job Category:
Revenue Cycle
Work Shift/Schedule:
8 Hr Morning - Afternoon
Northeast Georgia Health System is rooted in a foundation of improving the health of our communities.
The Coding Quality Reviewer II is responsible for performing quality analysis of coded medical records, documenting the analysis, summarizing the metrics and reporting quality statistics to management. Responsible for complex multi-specialty coding to include but not limited to: Neurosurgery, UI, Neurology, Critical Care, hospitalists, surgical and others as defined. The Coding Quality Reviewer II is also responsible for communicating identified issues to coding staff and management, as well as reviewing and correcting coding issues from the EMR and PMS systems. In addition, the Coding Quality Reviewer II may be called upon to provide education to staff and clients, prepare coding audits for physician education, and/or coding charts as business needs dictate.
The Coding Quality Reviewer II is responsible for providing and ensuring accurate, complete and timely coding of professional services to include all surgical and inpatient services. All coding staff must ensure accuracy and compliance with regulatory standards. Coding Quality Reviewer II is also responsible for performing audits in accordance with NGPG's annual Compliance Work Plan and preparing written and oral communications to the Coding Compliance Manager.
Minimum Job Qualifications
Licensure or other certifications: CPC and/or CCS-P Coding Certification required
Educational Requirements: High School Diploma or GED
Minimum Experience: Three (3) years experience coding Multi-Specialty records required.
Other:
Preferred Job Qualifications
Preferred Licensure or other certifications:
Preferred Educational Requirements:
Preferred Experience:
Other:
Job Specific and Unique Knowledge, Skills and Abilities
Extensive knowledge of ICD-9, CPT, HCPCS coding, medical terminology, federal and state regulatory guidelines and third party payor requirements required
Accuracy and attention to detail imperative
Ability to interact well with others at all levels with a flexible, energetic, proactive and positive style
In-depth knowledge of Optimal coding policy and procedures
Highly skilled proficient with Microsoft Office products
Ability to communicate (both verbally and written) technical coding information to both technical and non-technical audiences
Ability to organize data and provide detailed reporting
Ability to prepare presentations and present to large or small audiences
Must be highly motivated, detail oriented individual
Excellent written and oral communication skills
Problem solving and analytical skills
Ability to be a self starter/work independently and as a team player
Ability to travel to NGHS/NGPG sites as needed
Essential Tasks and Responsibilities
Perform timely, concurrent quality review of coded medical records.
Correct errors identified in the quality process in both EMR and PMS systems.
Maintain coding quality statistics and provide detailed reporting to management.
Communicate errors to the Posting, Clinicians and AR staff on an individual basis.
Communicate to management any problem areas identified in the quality process and steps taken to resolve.
Assist with the review and correction of coding errors in the billing process (TM queues).
Assist with the review and correction of coding errors in the electronic claims process (clearinghouse on-line errors).
Promptly and professionally respond to both verbal and written coding questions from the internal staff and other areas of the company.
Review documentation deficiencies for accuracy and communicate identified errors to the coding staff and management.
Prepare documentation audits as needed for on-site physician education.
Production coding of medical records as per business needs.
Adherence to Coding policy and procedures.
Review charge slips/cards for completeness (providers are ultimately responsible for codes they assign).
Attends Regional and Local sponsored in-services and/or continuing education.
Participates in professional development activities and maintains professional affiliations as necessary.
Provide and/or validate CPT, ICD-9-CM and HCPCS coding of professional services for outpatient clinics, outreach offices or programs, minor diagnostic procedures, and/or ancillary services.
Review charge tickets for missing or inaccurate information. Items reviewed include service and diagnosis codes units of service, modifiers, facility code, place of service, provider billing numbers, etc.
Communicate with providers and clinic staff to ensure charge capture of all professional services, supplies, drugs, vaccinations, etc.
Monitor reconciliation procedures to ensure all charges are captured and billed in a timely manner.
Research and correct claims manager edits in a timely manner by applying coding and carrier specific guidelines while maintaining compliance initiatives.
Provide coding coverage to other specialties, departments, divisions, and/or units as required.
Attend billing educational sessions to enhance coding knowledge i.e. American Academy of Professional Coders, Professional Medical Coding Curriculum, NGPG Compliance Proficiency training, specialty seminars.
Performs other job duties as assigned.
Cross trains in other positions as requested.
Physical Demands
Weight Lifted: Up to 20 lbs, Occasionally 0-30% of time
Weight Carried: Up to 20 lbs, Occasionally 0-30% of time
Vision: Moderate, Frequently 31-65% of time
Kneeling/Stooping/Bending: Occasionally 0-30%
Standing/Walking: Occasionally 0-30%
Pushing/Pulling: Occasionally 0-30%
Intensity of Work: Frequently 31-65%
Job Requires: Reading, Writing, Reasoning, Talking, Keyboarding, Driving
Working at NGHS means being part of something special: a team invested in you as a person, an employee, and in helping you reach your goals.
NGHS: Opportunities start here.
Northeast Georgia Health System is an Equal Opportunity Employer and will not tolerate discrimination in employment on the basis of race, color, age, sex, sexual orientation, gender identity or expression, religion, disability, ethnicity, national origin, marital status, protected veteran status, genetic information, or any other legally protected classification or status.
Auto-ApplyInpatient DRG Reviewer
Remote
At Zelis, we Get Stuff Done. So, let's get to it!
A Little About Us
Zelis is modernizing the healthcare financial experience across payers, providers, and healthcare consumers. We serve more than 750 payers, including the top five national health plans, regional health plans, TPAs and millions of healthcare providers and consumers across our platform of solutions. Zelis sees across the system to identify, optimize, and solve problems holistically with technology built by healthcare experts - driving real, measurable results for clients.
A Little About You
You bring a unique blend of personality and professional expertise to your work, inspiring others with your passion and dedication. Your career is a testament to your diverse experiences, community involvement, and the valuable lessons you've learned along the way. You are more than just your resume; you are a reflection of your achievements, the knowledge you've gained, and the personal interests that shape who you are.
Position Overview
The Inpatient DRG Reviewer will be primarily responsible for conducting post-service, pre-payment and post pay comprehensive inpatient DRG reviews based on industry standard inpatient coding guidelines and rules, evidence based clinical criteria plan, and policy exclusions. Conduct reviews on inpatient DRG claims as they compare with medical records ICD-10 Official Coding Guidelines, AHA Coding Clinic and client specific coverage policies. Conduct prompt claim review to support internal inventory management to achieve greatest savings for clients.
What you'll do:
Perform comprehensive inpatient DRG validation reviews to determine accuracy of the DRG billed, based on industry standard coding guidelines and the clinical evidence supplied by the provider in the form of medical records such as physician notes, lab tests, images (x-rays etc.), and with due consideration to any applicable medical policies, medical best practice, etc.
Based on the evidence presented in the medical records, determine, and record the appropriate (revised) Diagnosis Codes, Procedure Codes and Discharge Status Code applicable to the claim.
Using the revised codes, regroup the claim using provided software to determine the ‘new DRG'.
Determine where the regrouped ‘new DRG' differs from what was originally claimed by the provider, write a customer facing ‘rationale' or ‘findings' statement, highlighting the problems found and justifying the revised choices of new codes and DRG, based on the clinical evidence obtained during the review
Document all aspect of audits including uploading all provider communications, clinical rationale, and/or financial research
Identify new DRG coding concepts to expand the DRG product.
Manage assigned claims and claim report, adhering to client turnaround time, and department Standard Operating Procedures
Meet and/or exceed all internal and department productivity and quality standards
Recommend new methods to improve departmental procedures
Achieve and maintain personal production and savings quota
Maintain awareness of and ensure adherence to Zelis standards regarding privacy
What you'll bring to Zelis:
Registered Nurse licensure preferred
Inpatient Coding Certification required (i.e., CCS, CIC, RHIA, RHIT)
3 - 5 years reviewing and/or auditing ICD-10 CM, MS-DRG and APR-DRG claims preferred
Solid understanding of audit techniques, identification of revenue opportunities and financial negotiation with providers
Experience and working knowledge of Health Insurance, Medicare guidelines and various healthcare programs
Understanding of hospital coding and billing rules
Clinical skills to evaluate appropriate Medical Record Coding
Experience conducting root cause analysis and identifying solutions
Strong organization skills with attention to detail
Outstanding verbal and written communication skills
Please note at this time we are unable to proceed with candidates who require visa sponsorship now or in the future.
Location and Workplace Flexibility
We have offices in Atlanta GA, Boston MA, Morristown NJ, Plano TX, St. Louis MO, St. Petersburg FL, and Hyderabad, India. We foster a hybrid and remote friendly culture, and all our employee's work locations are based on the needs of the position and determined by the Leadership team. In-office work and activities, if applicable, vary based on the work and team objectives in accordance with Company policies.
Base Salary Range
$79,000.00 - $105,000.00
At Zelis we are committed to providing fair and equitable compensation packages. The base salary range allows us to make an offer that considers multiple individualized factors, including experience, education, qualifications, as well as job-related and industry-related knowledge and skills, etc. Base pay is just one part of our Total Rewards package, which may also include discretionary bonus plans, commissions, or other incentives depending on the role.
Zelis' full-time associates are eligible for a highly competitive benefits package as well, which demonstrates our commitment to our employees' health, well-being, and financial protection. The US-based benefits include a 401k plan with employer match, flexible paid time off, holidays, parental leaves, life and disability insurance, and health benefits including medical, dental, vision, and prescription drug coverage.
Equal Employment Opportunity
Zelis is proud to be an equal opportunity employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, age, sex, national origin, disability status, genetics, protected veteran status, sexual orientation, gender identity or expression, or any other characteristic protected by federal, state or local laws.
We welcome applicants from all backgrounds and encourage you to apply even if you don't meet 100% of the qualifications for the role. We believe in the value of diverse perspectives and experiences and are committed to building an inclusive workplace for all.
Accessibility Support
We are dedicated to ensuring our application process is accessible to all candidates. If you are a qualified individual with a disability or a disabled veteran and require a reasonable accommodation with any part of the application and/or interview process, please email ***************************.
Disclaimer
The above statements are intended to describe the general nature and level of work being performed by people assigned to this classification. They are not to be construed as an exhaustive list of all responsibilities, duties, and skills required of personnel so classified. All personnel may be required to perform duties outside of their normal responsibilities, duties, and skills from time to time.
Auto-ApplyInsurance Reviewer - Clinical
Eugene, OR jobs
Insurance Reviewer - Clinical Willamette Valley Cancer Institute is looking for an Insurance Reviewer to support our patients receiving testing and treatment needed for their diagnosis by navigating insurance portals and obtaining all appropriate authorizations. With a focus on authorizations for infusion drugs, radiation therapy, imaging, genetics and surgeries our Insurance Reviewers pave the way for our patients and treatment team to follow the prescribed treatment pathway. An individual that thrives in a high-volume workspace, with the ability to manage shifting priorities will find success in this role.
The general pay scale for this position at WVCI is $22.01-$31.00. The actual hiring rate is dependent on many factors, including but not limited to: prior work experience, education, job/position responsibilities, location, work performance, etc.
Employment Type: Full Time
Benefits: M/D/V, Life Ins., 401(k)
Location: Eugene, OR
Responsibilities
* Reviews, processes and audits the medical necessity for treatments including radiation oncology, gynecologic surgery, genetic lab testing, imaging, and chemotherapy treatment for each patient. Documentation of regimen related to pathway adherence and payer guidelines.
* Communicate with nursing, physician, pharmacists and medical staff to inform them of any restrictions or special requirements in accordance with particular insurance plans. Provides prompt feedback to physicians and management regarding pathway documentation issues, and payer issues with non-covered chemotherapy drugs.
* Updates coding/payer guidelines for clinical staff. Tracks pathways and performs various other business office functions on an as needed basis
* Obtains insurance authorization and pre-certification for various oncology & hematology related services.
* Maintains a good working knowledge of chemotherapy authorization requirements for all payers, State and federal regulatory guidelines for coverage and authorization. Adheres to confidentiality, state, federal, and HIPAA laws and guidelines with regards to patient's records.
* Other duties as requested or assigned.
Qualifications
* High school degree or equivalent.
* Minimum three (3) years of prior authorization experience required. Revenue cycle experience preferred.
PHYSICAL DEMANDS:
The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. While performing the duties of this job, the employee is required to be present at the employee site during regularly scheduled business hours and regularly required to sit or stand and talk or hear. Requires full range of body motion including handling and lifting patients, manual and finger dexterity, and eye-hand coordination. Requires standing and walking for extensive periods of time. Occasionally lifts and carries items weighing up to 40 lbs. Requires corrected vision and hearing to normal range.
Work Environment:
The work environment may include exposure to communicable diseases, toxic substances, ionizing radiation, medical preparations and other conditions common to an oncology/hematology clinic environment. Work will involve in-person interaction with co-workers and management and/or clients. Work may require minimal travel by automobile to office sites.
The US Oncology Network is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, or national origin.
Bill Reviewer III
Rocklin, CA jobs
Full-time Description
Employee is a Lead Bill Reviewer who will assist the Bill Review Supervisor in a variety of functions related to the ultimate goals of the department.
Candidate's commute to the nearest office location is more than 50 miles
Candidate must show exemplary productivity and performance
Candidate must report to the closest office as needed for personnel meetings and training and/or as supervisor requests (at a minimum, once a month).
Live in a location that can receive an approved high speed internet connection
Have a “meets” or “exceeds” performance rating on most current performance review and currently meeting all performance expectations.
Employee must not have an open Corrective Action Plan.
Under close supervision, meets daily production quotas in processing and auditing medical bills in accordance with the appropriate workers' compensation fee schedule by performing the following duties.
Essential Duties and Responsibilities:
Must be able to process all clients' bills to serve as a team backup for all clients.
Must be able to serve as a backup to the Bill Review Supervisor in day to day operations.
Non-exempt employees must log all time worked in the Paylocity system including log-in and log-off time as well as lunch time.
Codes medical bills into the company system with speed and accuracy, maintaining company production standards related to quantity and quality of output.
Performs preliminary screening for appropriateness and medical necessity of services rendered.
Uses CPT and ICD-10 codes, fee schedules, and other resource materials to determine appropriate reimbursement of billed services, including applicable fee schedule and/or repricing rational.
Flags any problem bills.
Communicates with clients and/or providers to clarify information
Assists with bill review reporting functions (internal and external reports)
May specialize in state specific or client specific areas of responsibility
May assist is answering provider calls.
May travel to other offices to assist with training
May be called upon to assist with sales and marketing presentations
Requirements
Competency:
To perform the job successfully, an individual should demonstrate the following competencies:
Design - Demonstrates attention to detail.
Oral Communication - Speaks clearly and persuasively in positive or negative situations; Listens and gets clarification; Responds well to questions.
Team Work - Supports everyone's efforts to succeed.
Quality - Demonstrates accuracy and thoroughness; Looks for ways to improve and promote quality; Applies feedback to improve performance; Monitors own work to ensure quality.
Quantity - Meets productivity standards; Completes work in timely manner; Strives to increase productivity; Works quickl
Qualification Requirements:
To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. Excellent oral and written communication skills.
Education and/or Experience:
High school diploma or general education degree (GED), plus minimum of one year data entry/medical billing experience; additional two years bill review experience in a workers' comp environment.
We're an equal opportunity employer. All applicants will be considered for employment without attention to race, color, religion, sex, sexual orientation, gender identity, national origin, veteran or disability status.
Pursuant to the Los Angeles and San Francisco Fair Chance Ordinance, we will consider for employment qualified applicants with arrest or conviction records.
Salary Description $25.00 - $30.00
Special Investigations Unit Medical Reviewer (Hybrid Work Schedule)
Rancho Cucamonga, CA jobs
What you can expect! Find joy in serving others with IEHP! We welcome you to join us in "healing and inspiring the human spirit" and to pivot from a "job" opportunity to an authentic experience! Under general supervision, the Special Investigations Unit Medical Reviewer (SIU Medical Reviewer) performs reviews of medical records and healthcare claims to substantiate or refute the accuracy and compliance with federal and state regulations and contractual requirements of codes billed to identify coding errors and billing discrepancies in relation to incidents of suspected healthcare fraud, waste, and abuse (FWA) reported to IEHP's Compliance Special Investigations Unit (SIU).
Commitment to Quality: The IEHP Team is committed to incorporate IEHP's Quality Program goals including, but not limited to, HEDIS, CAHPS, and NCQA Accreditation.
Perks
IEHP is not only committed to healing and inspiring the human spirit of our Members, but we also aim to match our team members with the same energy by providing prime benefits and more.
* Competitive salary
* Hybrid schedule
* State of the art fitness center on-site
* Medical Insurance with Dental and Vision
* Life, short-term, and long-term disability options
* Career advancement opportunities and professional development
* Wellness programs that promote a healthy work-life balance
* Flexible Spending Account - Health Care/Childcare
* CalPERS retirement
* 457(b) option with a contribution match
* Paid life insurance for employees
* Pet care insurance
Education & Requirements
* A minimum of two (2) years of experience performing medical reviews of medical records and claims in a healthcare setting
* Bachelor's degree in Medical Billing/Medical Coding, Nursing, Healthcare Administration, or related field from an accredited institution required
* In lieu of the required degree, a minimum of four (4) years of additional relevant work experience is required for this position
* This experience is in addition to the minimum years listed in the Experience Requirements above
* Certified Professional Coder (CPC), Certified Professional Medical Auditor (CPMA), or Certified Coding Specialist (CCS) required
* One of the following licenses preferred:
* Possession of an active, unrestricted, and unencumbered Vocational Nurse (LVN) license issued by the California Board of Vocational Nursing and Psychiatric Technicians
* Possession of an active, unrestricted, and unencumbered Registered Nurse (RN) license issued by the California BRN
Key Qualifications
* Must have a valid California Driver's license
* Strong understanding of medical coding, billing practices, and healthcare regulations
* Thorough understanding of ICD, CPT, HCPCS, DRG, revenue codes, NDC's and other guidelines and general understanding of investigative processes within a healthcare environment are required
* Knowledge of Medi-Cal and Medicare rules and regulations, and managed care in California is preferred
* Strong verbal and written communication, interpersonal skills, critical problem-solving skills, and attention to detail
* Above average proficiency in the use of technology applications, particularly Excel, Word, and others as necessary
* Detail-oriented with strong organizational and time management abilities. Ability to articulate medical review findings clearly and thoroughly
* Conduct research in support of medical reviews and make determinations on claims with a high level of accuracy
* Demonstrated ability to interpret and analyze healthcare data and records
* Adapt to different technology software and platforms, including anti-fraud solutions
* Ability to work independently and collaboratively with a team
Start your journey towards a thriving future with IEHP and apply TODAY!
Pay Range
* $71,572.80 USD Annually - $93,038.40 USD Annually
Inpatient DRG Sr. Reviewer
Remote
At Zelis, we Get Stuff Done. So, let's get to it!
A Little About Us
Zelis is modernizing the healthcare financial experience across payers, providers, and healthcare consumers. We serve more than 750 payers, including the top five national health plans, regional health plans, TPAs and millions of healthcare providers and consumers across our platform of solutions. Zelis sees across the system to identify, optimize, and solve problems holistically with technology built by healthcare experts - driving real, measurable results for clients.
A Little About You
You bring a unique blend of personality and professional expertise to your work, inspiring others with your passion and dedication. Your career is a testament to your diverse experiences, community involvement, and the valuable lessons you've learned along the way. You are more than just your resume; you are a reflection of your achievements, the knowledge you've gained, and the personal interests that shape who you are.
Position Overview
As part of the Price Optimization division, this role is responsible for conducting post-service, pre-payment and post pay comprehensive inpatient DRG Quality Assurance reviews in an effort to increase the savings achieved for Zelis clients. Conduct reviews on inpatient DRG claims as they compare with medical records utilizing ICD-10 Official Coding Guidelines, AHA Coding Clinic evidence based clinical criteria and client specific coverage policies.
What you'll do:
Perform comprehensive inpatient DRG validation Quality Assurance reviews to determine accuracy of the DRG billed, based on industry standard coding guidelines and the clinical evidence supplied by the provider in the form of medical records such as physician notes, lab tests, images (x-rays etc.), and with due consideration to any applicable medical policies, medical best practice, etc.
Implement and conduct quality assurance program to ensure accurate results to our clients
Manage assigned claims and claim report, adhering to client turnaround time, and department Standard Operating Procedures
Serve as the Subject Matter Expert on DRG validation to team members and other departments within the organization
Prepare and conduct training for new team members
Identify new DRG coding concepts to expand the DRG product
Meet and/or exceed all internal and department productivity and quality standards
Must remain current in all national coding guidelines including Official Coding Guidelines, AHA Coding Clinic and AMA CPT Assistant
Recommend efficiencies and process improvements to improve departmental procedures
Maintain awareness of and ensure adherence to Zelis standards regarding privacy
What you'll bring to Zelis:
Registered Nurse licensure preferred
Inpatient Coding Certification required (i.e., CCS, CIC, RHIA, RHIT)
5+ years reviewing and/or auditing ICD-10 CM, MS-DRG and APR-DRG claims preferred
Solid understanding of audit techniques, identification of revenue opportunities and financial negotiation with providers
Experience and working knowledge of Health Insurance, Medicare guidelines and various healthcare programs
Strong understanding of hospital coding and billing rules
Clinical and critical thinking skills to evaluate appropriate coding
Strong organization skills with attention to detail
Excellent communication skills both verbal and written, and skilled at developing and maintaining effective working relationships.
Demonstrated thought leadership and motivation skills, a self-starter with an ability to research and resolve issues
Please note at this time we are unable to proceed with candidates who require visa sponsorship now or in the future.
Location and Workplace Flexibility
We have offices in Atlanta GA, Boston MA, Morristown NJ, Plano TX, St. Louis MO, St. Petersburg FL, and Hyderabad, India. We foster a hybrid and remote friendly culture, and all our employee's work locations are based on the needs of the position and determined by the Leadership team. In-office work and activities, if applicable, vary based on the work and team objectives in accordance with Company policies.
Base Salary Range
$95,000.00 - $127,000.00
At Zelis we are committed to providing fair and equitable compensation packages. The base salary range allows us to make an offer that considers multiple individualized factors, including experience, education, qualifications, as well as job-related and industry-related knowledge and skills, etc. Base pay is just one part of our Total Rewards package, which may also include discretionary bonus plans, commissions, or other incentives depending on the role.
Zelis' full-time associates are eligible for a highly competitive benefits package as well, which demonstrates our commitment to our employees' health, well-being, and financial protection. The US-based benefits include a 401k plan with employer match, flexible paid time off, holidays, parental leaves, life and disability insurance, and health benefits including medical, dental, vision, and prescription drug coverage.
Equal Employment Opportunity
Zelis is proud to be an equal opportunity employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, age, sex, national origin, disability status, genetics, protected veteran status, sexual orientation, gender identity or expression, or any other characteristic protected by federal, state or local laws.
We welcome applicants from all backgrounds and encourage you to apply even if you don't meet 100% of the qualifications for the role. We believe in the value of diverse perspectives and experiences and are committed to building an inclusive workplace for all.
Accessibility Support
We are dedicated to ensuring our application process is accessible to all candidates. If you are a qualified individual with a disability or a disabled veteran and require a reasonable accommodation with any part of the application and/or interview process, please email ***************************.
Disclaimer
The above statements are intended to describe the general nature and level of work being performed by people assigned to this classification. They are not to be construed as an exhaustive list of all responsibilities, duties, and skills required of personnel so classified. All personnel may be required to perform duties outside of their normal responsibilities, duties, and skills from time to time.
Auto-ApplyBill Reviewer III
Orange, CA jobs
Full-time Description
Employee is a Lead Bill Reviewer who will assist the Bill Review Supervisor in a variety of functions related to the ultimate goals of the department.
Candidate's commute to the nearest office location is more than 50 miles
Candidate must show exemplary productivity and performance
Candidate must report to the closest office as needed for personnel meetings and training and/or as supervisor requests (at a minimum, once a month).
Live in a location that can receive an approved high speed internet connection
Have a “meets” or “exceeds” performance rating on most current performance review and currently meeting all performance expectations.
Employee must not have an open Corrective Action Plan.
Under close supervision, meets daily production quotas in processing and auditing medical bills in accordance with the appropriate workers' compensation fee schedule by performing the following duties.
Essential Duties and Responsibilities:
Must be able to process all clients' bills to serve as a team backup for all clients.
Must be able to serve as a backup to the Bill Review Supervisor in day to day operations.
Non-exempt employees must log all time worked in the Paylocity system including log-in and log-off time as well as lunch time.
Codes medical bills into the company system with speed and accuracy, maintaining company production standards related to quantity and quality of output.
Performs preliminary screening for appropriateness and medical necessity of services rendered.
Uses CPT and ICD-10 codes, fee schedules, and other resource materials to determine appropriate reimbursement of billed services, including applicable fee schedule and/or repricing rational.
Flags any problem bills.
Communicates with clients and/or providers to clarify information
Assists with bill review reporting functions (internal and external reports)
May specialize in state specific or client specific areas of responsibility
May assist is answering provider calls.
May travel to other offices to assist with training
May be called upon to assist with sales and marketing presentations
Requirements
Competency:
To perform the job successfully, an individual should demonstrate the following competencies:
Design - Demonstrates attention to detail.
Oral Communication - Speaks clearly and persuasively in positive or negative situations; Listens and gets clarification; Responds well to questions.
Team Work - Supports everyone's efforts to succeed.
Quality - Demonstrates accuracy and thoroughness; Looks for ways to improve and promote quality; Applies feedback to improve performance; Monitors own work to ensure quality.
Quantity - Meets productivity standards; Completes work in timely manner; Strives to increase productivity; Works quickl
Qualification Requirements:
To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. Excellent oral and written communication skills.
Education and/or Experience:
High school diploma or general education degree (GED), plus minimum of one year data entry/medical billing experience; additional two years bill review experience in a workers' comp environment.
We're an equal opportunity employer. All applicants will be considered for employment without attention to race, color, religion, sex, sexual orientation, gender identity, national origin, veteran or disability status.
Pursuant to the Los Angeles and San Francisco Fair Chance Ordinance, we will consider for employment qualified applicants with arrest or conviction records.
Salary Description $25.00 - $30.00