Position Overview
Provides clinical review expertise for high dollar and complex claims, including facility and professional bills. Provides cost containment services by identifying coding and billing errors and insuring application of Medical and Reimbursement Policies. Additionally identifies cases for potential fraud and abuse and makes referrals.
Major Job Responsibilities
Evaluates medical information against criteria, benefit plan, coverage policies and determines necessity for procedure and refers to Medical Director if criteria are not metEvaluate itemized bills against reimbursement policiesAdheres to quality assurance standardsServes as a resource to facilitate understanding of productsHandles some escalated cases; secures supervisory assistance with problem solving and decision makingAdvises supervisory staff of any concerns or complaints expressed by Health Care ProfessionalsUtilizes effective communication, courtes...