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Centene Corporation Clinical Reviewer II RN (Special Investigation Unit) in Des Moines, Iowa

Position Purpose:

  • Perform complex retrospective and prepayment reviews of medical records to identify potential abuse and fraud and inappropriate billing practices.

  • Responsible for second level appeals reviews

  • Investigate, analyze, and identify provider billing patterns to recommend payment based on medical records, claim history, billing codes, regulatory and state guidelines, and policies

  • Prepare summary of findings and recommend next steps for providers

  • Identify preventative measures and recommend changes to internal policies and procedures and/or provider practices to prevent future fraudulent and erroneous practices.

  • Consult investigators to identify abuse and fraud by utilizing clinical and coding expertise to analyze patterns in billing activities

  • Perform onsite audits in conjunction with investigators and/or managers.

  • Review providers’ claims history, licensure, and specialty. Assess providers by interviewing staff, examining the facility and equipment, and reviewing medical records

  • Provide instructions to the claims department for prepayment reviews

  • Assist SIU Clinical Supervisor/Manager as needed with training new hires, answering questions from Clinical Reviewer I employees, auditing work of junior-level employees, assisting with provider education, and answering questions from investigators

  • Audit medical records to identify inappropriate billing practices and determine medical necessity through extensive review of claims data, medical records, corporate policies, state/federal policies, and the interpretation of practice standards

Experience/Experience:

Associate’s degree in Nursing, Counseling, or related field. Coding Certification and 4+ years of medical coding experience; or RN, LPC, LCSW, LMHC, PT, OT or ST license and 4+ years of related clinical experience in the field of obtained license. Experience in provider education preferred. Experience in a managed care organization preferred. Experience in medical record auditing preferred.

Licenses/Certifications:

Coding certification from an accredited organization (American Academy of Professional Coders or American Health Information Management Association), RN, LPC, LCSW, LMHC, PT, OT, or ST.

Centene is an equal opportunity employer that is committed to diversity, and values the ways in which we are different. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, veteran status, or other characteristic protected by applicable law.

TITLE: Clinical Reviewer II RN (Special Investigation Unit)

LOCATION: Des Moines, Iowa

REQNUMBER: 1190790

COMPANY: Quality

POSITION TYPE: Both

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