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The Medical Review Audit Supervisor - Clinical leverages their nursing background, deep knowledge of clinical review, and experience leading others to manage staff and operational results for a remote team of nurses and other audit roles, performing clinical review audits. The Supervisor will leverage first-hand experience and knowledge of claims auditing for supporting management with strategy activities such as needs assessments, capacity planning, and ensuring required staffing levels and productivity & quality standards are being achieved consistently.
 

Key Responsibilities to include:

• Regularly performs limited volume of clinical audits to maintain subject matter expertise, and additionally as needed to support business needs.

• Performs audit quality assurance reviews to supplement QA team activity as necessary based upon business need or special projects.

• Contributes to the resolution of quality review rebuttals.

• May perform appeals review/activity to supplement Appeals team, based upon business need.

• Actively identifies and recommends opportunities for cost savings and improving outcomes that can have a direct impact to the company's profitability.

• Effectively ensures adherence to medical review guidelines and training requirements of staff.

• Supports audit management and segment specialists with activities for new concept implementation

• Supports management with needs assessments and capacity planning

• Monitor and manage inventory of assigned business to ensure timelines are met. 

• Use data, reports and experience to proactively identify potential backlogs and align resources to meet business needs and SLAs.

• Oversee and review audit determinations to ensure consistency in decision-making.

• Collaborate with other departments to resolve operational problems.

• Proactively monitors and in alignment with applicable management ensures activity required to meet team staffing levels necessary to achieve business objectives.

• Provides support as needed to ensure auditors are equipped with tools and resources required to perform audits.

• Supervise daily activities of clinical audit staff that may include both salaried exempt and hourly employees.

• Provide audit guidance to medical review staff; identify trends and present solutions.

• Routinely provides production and quality performance-based progress reports, coaching, and constructive feedback to staff.

• Manages team Time and Attendance (time off/use of accruals, attendance, attendance points and timecards for hourly staff, etc.) in accordance with applicable policies and procedures.

• Collaborates with The People Team for applicable corrective action as applicable.

• Complete and conduct performance reviews for assigned staff.

• Conduct team meetings with direct reports on a regular basis.

• Provide leadership to team members, provide solutions, and resolve conflicts.

• Escalate to management and collaborate with HR as applicable to bring appropriate solutions to employee matters.

• Provide reporting and updates to management as required and appropriate for operational and staff activity and results.

• Participates in and contributes to applicable department meetings.

• May participate to client-facing meetings; research and analyze issues; present findings and solutions; and/or provider training.

• May support management with activities to monitor inventory and activity of 3rd party/subcontractors.

• Become subject matter expert for assigned business segment(s).

• Maintain current knowledge and changes that affect our industry and clients as it pertains to medical practice, technology, regulations, legislation and business trends.

• May support training material/tools and best practices development.

• Identify needs and ensure team receives necessary training.

• Support training activities for new audit staff or provide supplemental training for existing staff as needed.

• Contributes to positive team environment that fosters open communication, sharing of information, continuous improvement, and optimized business results.

• Receives feedback and adjusts work priority for self and team as necessary.

• Leads by example and conducts work in accordance with company policies, government regulations and law.

• Perform other incidental and related duties as required and assigned to meet business needs.

Knowledge, Skills and Abilities Needed:

• Strong knowledge of medical documentation requirements and an understanding CMS, Medicaid and/or Commercial insurance programs, particularly the coverage and payment rules.

• Experience with CPT/HCPCs/ICD-9/ICD-10/MS-DRG coding. 

• Proficiency with MCS 1500/UB 04 forms

• Working knowledge of encoder

• Experience with utilization management systems or clinical decision-making tools such as Medical Coverage Guidelines, Milliman or InterQual.

• Proven ability to review, analyze, and research medical billing, documentation, and coding issues

• Reimbursement policy and/or claims software analyst experience

• Familiarity with interpreting electronic medical records (EHR)

• Willing and able to lead by example, communicate ideas, take initiative and drive the team to achieve organizational goals.

• Experience in developing, documenting and implementing process and procedures.

• Experience in inventory management, resource planning and report generation.

• Skill in analyzing information, identifying trends and presenting solutions.

• Understands inventory management objectives, activities, and key drivers in achieving operational goals.

• Demonstrated ability to consistently apply sound judgment and good effective decision making.

• Excellent communication skills, both verbal and written; ability to communicate effectively and professionally at all levels within the organization, both internal external.

• Demonstrated ability to collaborate effectively in a variety of settings and topics.

• Excellent editing and proofreading skills.

• Demonstrated ability to successfully develop, lead, and motivate a team to high performance; effectively provides constructive feedback and coaching for successful outcomes.

• Ability to independently organization, prioritize and plan work activities effectively for self and others; develops realistic action plans with the ability to multi-task effectively.

• Excellent time management and delivers results balancing multiple priorities.

• Strong analytical skills; synthesizes complex or diverse information; collects and researches data; uses experience to compliment data.

• Leverages strong critical thinking, questioning, and listening skills to research and effectively resolve complex issues.

• Demonstrated ability to identify areas of opportunity and create efficiencies in workflows and procedures.

• Demonstrated ability to be proactive; identifies and resolves problems in a timely manner; develops alternative solutions.

• Ability to create documentation outlining findings and/or documenting suggestions.

• Strong general technical skills, including, but not limited to Desktop and MS Office applications (Intermediate Excel Skills), application reporting tools, and case management system/tools to review and document findings.

• Solid technical aptitude with demonstrated ability to quickly learn and adapt to new systems and tools.

• Ability to be flexible and thrive in a high pace environment with changing priorities.

• Adaptable to applying skills to diverse operational activities to support business needs.

• Self-starter with the ability to work independently in remote setting with minimum supervision and direction in the form of objectives.

• Serves as positive role model, and demonstrates characteristics that align and contribute to a collaborative culture of continuous improvement and high performing teams.

Required and Preferred Qualifications:

• Current active unrestricted Nursing license in good standing required.  Not currently sanctioned or excluded from the Medicare program by OIG, is also required.

• Medical coding certification is a plus.

• 3+ years diverse nursing experience providing direct care in an inpatient or outpatient setting.

• 2+ years of performing medical record audits in a provider setting, or in a payer setting for a health insurance company. 

• 5+ years in health care claims that demonstrates expertise in ICD-9/ICD-10 coding, HCPS/CPT coding, DRG and medical billing experience for an Insurance Company or hospital required. Those who have less than 5 years experience may be considered based upon demonstrated skills and/or formal training and other relevant experiences

• 3+ years relevant supervisory or leadership experience in similar business environment, preferred.  Experience managing remote staff is a plus.

• Some Supervisory experience may be required for certain Supervisor roles.

• Prior experience in payer edit development, and/or reimbursement policy experience a plus.