Manager, Clinical Review
$87,700–$157,800 year
RemoteUnited States
Job Summary
Manage resources and results of clinical reviews for providers/claims identified for potential fraud, waste, and abuse. Oversee complex FWA cases, audit reports, and cost savings analysis while developing medical strategies to correct billing issues. Lead a team of clinical investigators, conduct continuous educational training on appropriate billing patterns, and present findings to Upper Management. Collaborate with providers, medical management, and legal teams to define medical policy based on coding research and support state and federal legal actions. Validate medical decisions with Medical Directors to track clinical denials and ensure effective audit processes.
Required Qualifications
- Bachelor's Degree For Physical Health: Nursing, related field
- 5+ years For Physical Health: Medical coding and/or nursing experience
- Strong medical terminology and research techniques
- Knowledge of CPT code billing
- Previous experience managing cross functional teams on large scale projects or supervisory experience including hiring, training, assigning work and managing the performance of staff
- Certified Professional Coder
- RN or LPN
Desired Qualifications
- Clinical experience including hospital or clinic setting, emergency room and/or physician office
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