Job Description

The Medical Review Supervisor is responsible for overseeing activities and personnel involved in the day to day operations of CommunityCare's medical claim review program. The Supervisor guides individuals in implementing auditing and monitoring functions aimed at identifying areas of risk and/or potential fraud, waste and abuse, as it relates to provider billing practices.

KEY RESPONSIBILITIES:

Provides technical expertise to Medical Review (MRE) staff including analysis, problem solving, and decision making of complex claim reviews. Identifies medical necessity and /or quality issues for further evaluation. Oversees triage of pended and high dollar claims. Collaborates with external vendors on cases meeting reinsurance thresholds and specific requirements for ASO lines of business. Works collaboratively with other departments in providing or seeking claims review and/or clinical guidance. Participates in company committees or work groups as assigned. Proactively conducts routine monitoring and identifies areas of potential fraud, waste and/or abuse (FWA). Formulates recommendations based on findings. Suggests opportunities for focused reviews. Works collaboratively with the Compliance Officer and/or Special Investigations (SIU) as needed. Coordinates and/or oversees daily activities of the MRE staff. This includes planning, implementing and evaluating MRE goals. It also includes monitoring workload, staff supervision, training, coaching, auditing, teambuilding, performance evaluation and hiring/retaining staff. Provides training for new MRE staff including one-to-one sessions as required for successful staff mastery of job tasks related to claim reviews and special projects. Develops and implements operational guidelines for applicable payment policies and/or for other processes pertaining to the medical claim review function. Seeks organizational approval as indicated. Monitors the medical claim review tracking database for quality control. Compiles and analyzes data and prepares routine compliance reports. Performs other duties as required.

QUALIFICATIONS:

Excellent analytical and problem-solving skills Able to work independently as well as supervise others to meet stringent deadlines Strong attention to detail. Highly organized and capable of managing multiple projects. Proficient in Microsoft applications. Possess strong oral and written communication. Ability to work as a team in a high paced environment. Successful completion of Health Care Sanctions background check.

EDUCATION/EXPERIENCE

Current active, unrestrictive license to practice as a Registered Nurse (RN) in the State of Oklahoma. BSN preferred Minimum of five years combined employment in facility/provider health care settings or managed care organization. Two years supervisory experience preferred. Prefer strong clinical related background and case review experience focused in healthcare fraud, waste and abuse. Require experience or familiarity with state and federal regulations governing healthcare coding, billing and claims processing. Recognized healthcare coding certification (CPC, AHIMA, etc.) preferred.

CommunityCare is an equal opportunity at will employer and does not discriminate against any employee or applicant for employment because of age, race, religion, color, disability, sex, sexual orientation or national origin