Program Integrity Clinical Reviewer II (Readmission experience preferred)
Not Disclosed•Full-TimeOn-site
location_onOn-site
About the Role
The Program Integrity Clinical Reviewer II serves as a critical partner in CareSource's investigative process, dedicated to ensuring the accuracy and integrity of medical claims. This role goes beyond simple review; it involves a deep dive into medical records to identify trends, patterns, missing information, and potential issues such as upcoding or unbundling. With a specific emphasis on readmissions, the reviewer acts as a bridge between clinical documentation and financial standards, ensuring compliance with CPT, HCPCS, and ICD-10 codes.
In this position, you will not only evaluate claims for prepayment, post-payment, and Special Investigations Unit (SIU) teams but also collaborate with Medical Directors and physician experts to validate clinical findings. The role is dynamic, requiring you to draft corrective action plans, develop training materials, and provide strategic SIU perspectives to policy development committees. You will work across departments including Pharmacy, Legal, and Provider Relations, fostering a collaborative environment where data-driven insights lead to improved care delivery and operational efficiency.
Our Commitment to Culture
CareSource is an Equal Opportunity Employer dedicated to fostering an environment of belonging that welcomes and supports individuals of all backgrounds. We believe that a diverse workforce drives better outcomes for our members and our community. We are committed to creating a collaborative workplace culture where employees are encouraged to develop themselves and others, drive execution, and pursue personal excellence. Our total rewards package reflects our investment in every employee's well-being, supporting a balanced and fulfilling career.
Application Process
Candidates with a Bachelor of Science degree, a minimum of five years of clinical practice experience, and current RN licensure are encouraged to apply. Please note that Certified Medical Coder credentials (CPC, RHIT, or RHIA) are required at the time of hire or within 18 months. We review applications based on a combination of education, training, experience, and the specific scope of the role. CareSource reserves the right to amend this job description at any time.
Work location
Work model: On-site
On-site
Key Responsibilities
- check_circleConduct claim reviews against medical records to determine claim accuracy for prepayment, post-payment, and SIU teams
- check_circlePresent identified clinical issues and research to Medical Directors and physician experts for validation
- check_circleConduct and participate in on-site audits and investigations of medical professionals and contracted entities
- check_circleDraft provider education and formal corrective action plans for clinical and coding deficiencies
- check_circleProvide SIU perspective to the development of clinical and payment policies
- check_circleCollaborate with departments including Pharmacy, Medical Management, Claims, and Legal
- check_circleDevelop and maintain SIU specific clinical and investigative training materials and SOPs
- check_circleCreate and deliver training mediums such as presentations and quick reference tools
- check_circleAssist audit teams in developing clinical and coding based audit tools
- check_circleCreate and execute monthly audits of investigative staff work to ensure process compliance
Requirements
- verifiedBachelor of Science Degree or equivalent experience
- verifiedMinimum of five (5) years clinical practice experience
- verifiedSignificant experience auditing medical records against claims
- verifiedCPT, HCPCS and ICD-10 coding knowledge
- verifiedCurrent, unrestricted RN licensure in state of practice
- verifiedCertified Medical Coder (CPC, RHIT or RHIA) required at hire or within 18 months
Nice to Have
Prior Fraud, Waste, Abuse (FWA) investigation and auditing experience. Medical research experience. Knowledge of Medicare/Medicaid/Managed Care.
Benefits & Perks
check_circleSubstantial and comprehensive total rewards packagecheck_circlePerformance-based bonus opportunity
Similar Job Opportunities
Skills, education and keywords
Skills: CPT, HCPCS, Icd-10, Microsoft Office Word, Microsoft Office Excel, Microsoft Office Powerpoint, RN Licensure, CPC, Rhit, Rhia.
Education: Bachelor of Science Degree or equivalent experience is required.
Frequently asked questions about Program Integrity Clinical Reviewer II (Readmission experience preferred) at CareSource
What does a Program Integrity Clinical Reviewer II (Readmission experience preferred) at CareSource do?expand_more
Day-to-day, the Program Integrity Clinical Reviewer II (Readmission experience preferred) at CareSource will conduct claim reviews against medical records to determine claim accuracy for prepayment, post-payment, and siu teams; present identified clinical issues and research to medical directors and physician experts for validation; conduct and participate in on-site audits and investigations of medical professionals and contracted entities; and draft provider education and formal corrective action plans for clinical and coding deficiencies.
What are the requirements for this Program Integrity Clinical Reviewer II (Readmission experience preferred) role?expand_more
CareSource is looking for candidates who meet the following requirements: Bachelor of Science Degree or equivalent experience; Minimum of five (5) years clinical practice experience; Significant experience auditing medical records against claims; CPT, HCPCS and ICD-10 coding knowledge; Current, unrestricted RN licensure in state of practice; and Certified Medical Coder (CPC, RHIT or RHIA) required at hire or within 18 months.
Where is the Program Integrity Clinical Reviewer II (Readmission experience preferred) role at CareSource located?expand_more
Program Integrity Clinical Reviewer II (Readmission experience preferred) at CareSource is based in On-site. This is a on-site role.
Is this Program Integrity Clinical Reviewer II (Readmission experience preferred) job remote, hybrid, or on-site?expand_more
CareSource has listed this Program Integrity Clinical Reviewer II (Readmission experience preferred) role as on-site.
How much experience is required for this Program Integrity Clinical Reviewer II (Readmission experience preferred) role?expand_more
Program Integrity Clinical Reviewer II (Readmission experience preferred) at CareSource typically requires 5+ years of relevant experience at the senior level.
What skills do you need for the Program Integrity Clinical Reviewer II (Readmission experience preferred) role at CareSource?expand_more
Key skills for Program Integrity Clinical Reviewer II (Readmission experience preferred) at CareSource include CPT; HCPCS; Icd-10; Microsoft Office Word; Microsoft Office Excel; Microsoft Office Powerpoint; RN Licensure; and CPC.
What education is required for Program Integrity Clinical Reviewer II (Readmission experience preferred) at CareSource?expand_more
Educational requirements for this role: Bachelor of Science Degree or equivalent experience is required.
What category does the Program Integrity Clinical Reviewer II (Readmission experience preferred) role belong to?expand_more
Program Integrity Clinical Reviewer II (Readmission experience preferred) at CareSource is part of the admin job category on Recrutus.
About CareSource
CareSource, headquartered in Dayton, Ohio, operates within the health insurance sector with a focus on delivering member-centric healthcare solutions. For over three decades, the organization has prioritized improving the health and well-being of individuals and communities, emphasizing a business model that places people above profits. The company serves a diverse population of more than 2 million members across the United States through a range of coverage options, including Marketplace plans, Medicare products, and Medicaid services.
With a workforce exceeding 4,500 employees stationed in various locations nationwide, CareSource supports its mission to provide a lifetime of health coverage and clear pathways to better lives for its members. The organization remains committed to its core value of being member-first, ensuring that growth does not dilute its dedication to making a tangible difference in the lives of those it serves. CareSource operates as an equal opportunity employer, providing consideration to qualified applicants without regard to race, color, religion, sex, age, national origin, disability, sexual orientation, gender identity, genetic information, or protected veteran status, in compliance with all applicable federal, state, and local laws.
Browse more roles: All CareSource jobs, admin jobs on Recrutus.