Job SummaryResponsible for the management of clinical reviews to assist in the prevention and detection of fraud, waste and abuse in all the Health Plan lines of business. Plan, organize, and execute medical reviews or audits that identify, evaluate and measure potential healthcare fraud and abuse.Job DutiesUtilizes an expert knowledge of CPT, ICD-9, HCPCS coding and the Health Plan clinical and reimbursement policies to review and analyze claims and corresponding medical records for clinical medical record reviews.Prepares concise clinical review summaries to support findings of potential fraud, waste and abuse Conducts in-depth research and makes recommendations to clarify coding and billing issues identified in fraud, waste and abuse cases.
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Case Management Society of America 5034A Thoroughbred Lane Brentwood, TN 37027