Manager, Clinical Review

Remote position based in Missouri.

About the role

Manage the resources and results of clinical reviews triggered by providers or claims flagged for potential fraud, waste, and/or abuse. Oversee the review and audit processes of inappropriate billing practices and develop medical strategies to correct issues.

Responsibilities

• Lead and develop a team of clinical investigators.
• Review and evaluate complex Fraud, Waste & Abuse cases.
• Apply clinical expertise to identify trends, risks, and potential concerns.
• Review audit reports to ensure accuracy and completeness; present findings to Upper Management.
• Collaborate with providers and conduct continuous educational training on appropriate billing patterns.
• Support legal actions taken by the corporation, state, and federal governments.
• Oversee the implementation of improvement opportunities to ensure effective and efficient audit processes.
• Collaborate with the medical management department to help define medical policy based on coding research and review of medical records.
• Oversee and review cost savings analysis; meet with Medical Director(s) to validate medical decisions and track cost savings based on clinical denials.
• Perform other duties as assigned.
• Comply with all policies and standards.

Requirements

• Bachelor’s Degree in Nursing, related field, or equivalent experience.
• 5+ years of medical coding and/or nursing experience.
• Strong medical terminology and research techniques.
• Knowledge of CPT code billing.
• Previous experience managing cross-functional teams on large-scale projects or supervisory experience, including hiring, training, assigning work, and managing performance.
• Clinical experience in a hospital or clinic setting, emergency room, and/or physician office preferred.
• Certified Professional Coder, RN, or LPN certification a plus.

Pay

$87,700.00 - $157,800.00 per year. Actual pay will be adjusted based on an individual’s skills, experience, education, and other job-related factors permitted by law, including full-time or part-time status. Total compensation may also include additional forms of incentives.

Benefits

• Competitive pay.
• Health insurance.
• 401K and stock purchase plans.
• Tuition reimbursement.
• Paid time off plus holidays.
• Flexible approach to work with remote, hybrid, field, or office work schedules.