iHealth Technologies´ Inpatient Claims Review Services is a nationwide healthcare cost management company specializing in the review of inpatient claims. We´re looking for a RN who has experience in management, auditing, and coding. (relo considered)
The Manager of Clinical Audit will manage the audit workflows, interacting at the audit and auditor level to successfully ensure audit accuracy, audit assignments, and audit timeliness. Produce audit results consistent with Medicare PIM manual guidelines and Medicare Advantage guidelines. Understand and apply the Commercial guidelines for Commercial plans. Manage the Appeal processes to assure compliance and timely communications. Produce metrics supporting documentation of efficacy, accuracy, auditor payroll submissions, and audit progressions. PRIMARY RESPONSIBILITIES:1. DRG auditing administrator/manager 2. Manage the audit workflow assuring accurate and timely results3. Manage Contracting audit staff and oversee all aspects of their assignments4. Coordinate with internal staff to resolution of all audits5. Support MDs on OBV results and Medical Director appeals6. Critical link between care providers, payers, the contractors7. Provide an action plan and workflow to keep the audit process progressing 8. Provide data metrics on progress9. OBV audit challenges that may need to be reviewed for preview before submission. REQUIREMENTS:1. 2 + years Knowledge and working relationship with Medicare/Medicaid Regulations2. Degree in Healthcare Administration or similar3. Is an expert in managing patient health information and medical records, administering computer information systems, collecting and analyzing audit and DRG data, and using classification systems and medical terminologies4. Familiarity with Health Plan Operations desired5. Possesses comprehensive knowledge of medical, administrative, ethical and legal requirements and standards related to healthcare delivery and the privacy of protected patient information. 6. Able to Interacts with all levels of our organization clinical, financial, administrative, and information systems that employ audit data in decision-making and everyday operations7. Knowledge of competing technologies desired8. Excellent verbal and written communications and excellent phone etiquette9. Computer literacy required, Microsoft Office Suite, email, and using Web Based applicationsMINIMUM QUALIFICATIONS:1. Minimum 5 years of direct management experience2. Minimum 5 years of health plan operations experience3. Register Nurse (RN) required, Masters degree preferred4. Strong knowledge and capability for process improvement, process management, and measurement; Six Sigma certification preferred5. Demonstrated experience and capability of organizational skills, sound judgment and decision making, people management, and results focus.6. 2+ years experience as a Certified Coder designation, such as CPC or CCS. RHIT, RHIA 7. 2+ years Experience with DRG auditing8. Experience with a DRG grouper JOB DEMANDS:1. Some requirement to travel; up to 10%2. Work from Norwalk, CT office majority of time.3. Ability to work seated at a computer for long periods of time.4. After hours and/or weekend work required where necessary for major deliverables/deadlines (not consistent).OTHER INFORMATION: 1. Travel is required 2. iHealth Technologies offers competitive salary, a comprehensive benefits package, and an excellent working environment. 3. iHealth Technologies is an equal opportunity employer. iHealth Technologies is in full and active compliance with Title VII of the Civil Rights Act of 1964 (Title VII) which prohibits race, color, religion, sex, and national origin discrimination. iHealth Technologies complies with the Age Discrimination in Employment Act of 1967 (ADEA) which prohibits age discrimination against individuals who are forty (40) years of age or older, and Title I of the Americans with Disabilities Act of 1990 (ADA) which prohibits employment discrimination against qualified individuals with disabilities.