Vespa Group is Hiring a Senior Clinician Reviewer.

Position Purpose: The Senior Clinician Reviewer coordinates the Medical Review workload for both prepayment and post-payment reviews, assists with forecasting for metrics, and answers clinical questions regarding rules and regulations and the review process for internal and external sources.

Description/Duties:

Performs medical record reviews to determine compliance with regulations and standards instituted by the Indiana Health Coverage Programs, Centers for Medicare & Medicaid Services, American Medical Association, as well as other applicable standards.
Monitors the progress of each medical review case within the case tracking system and ensures that appropriate actions are taken.
Conducts medical record reviews or compliance reviews independently and submits preliminary findings to the Lead Clinical Reviewer.
Prepares the draft audit findings, administrative reconsideration, and final audit findings reports for medical reviews conducted and escalates for Lead Clinical Reviewer approval.
Prepares medical record review workpapers detailing the procedures performed, supporting documentation obtained and conclusions reached to support audit findings.
Assists with the appeals process as necessary.
Ensures appropriate outcomes; practice and adhere to state, federal, and national guidelines.
Stays abreast to changes in clinical guidelines, state and federal policies and regulations.
Research Indiana Medicaid rules and regulations and update repository with new bulletins, policies, and procedures.
Other duties as assigned.

Requirements:

Valid Registered Nursing license
Certified Coder
Certified Fraud Examiner is a plus

Vespa Group is an equal opportunity employer. All qualified applicants will be considered without regard to race, religion, color, national origin, sex, sexual orientation, gender identity, age, genetic information, status as a protected veteran or status as a qualified Individual with a Disability, or any other characteristic protected by applicable federal, state or local law. For more information please visit www.vespa-group.com.

Job Type: Full-time

Pay: $105,000.00 - $120,000.00 per year

Benefits:

Dental insurance
Health insurance
Paid time off
Vision insurance

Schedule:

Monday to Friday

Education:

Bachelor's (Required)

Experience:

working with Medicaid and Medicare: 4 years (Required)

License/Certification:

RN License (Required)
Certified Fraud Examiner (Required)
Certified Coding Specialist (Required)

Work Location: Remote

Vespa Group

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Senior Clinical Reviewer