Conduct claim reviews against medical records to determine claim accuracy for claims payment
Conduct meetings to present identified clinical issues and associated research to Medical Directors and physician experts for validation
Conduct, participate or contribute to on-site audits and investigations of medical professionals, subcontractors, and contracted entities
Assist the audit and investigative teams in the development of clinical and coding based audit tools
Draft proposed provider education and formal corrective action plans for clinical and coding deficiencies
Collaborate with other departments including Pharmacy, Medical Management, Provider Relations, Claims, Contracting, Case Management and Legal
Responsible for maintaining confidentiality of all sensitive investigative information
Develop and maintain SIU specific clinical and investigative training materials to include processes (SOPs)

Bachelor of Science Degree or equivalent experience required
Minimum of five (5) years clinical practice experience required
Significant experience auditing medical records against claims is required
Prior Fraud, Waste, Abuse (FWA) investigation and auditing experience preferred
Medical research experience is preferred
CPT, HCPCS and ICD-10 coding knowledge is required
Knowledge of Medicare/Medicaid/Managed Care preferred
Proficient with Microsoft Office Word, Excel and PowerPoint
Excellent written and verbal communication skills with adeptness to create, present and evaluate teaching materials

Program Integrity Clinical Reviewer II, Readmission Experience Preferred

Key skills