Responsible for pre and post payment review of complex hospital and physician cases to evaluate the medical necessity, appropriateness and quality of health care services. The Ambulatory Review Specialist will support the Coding Compliance program by conducting provider/facility audits to analyze coding, payment and practice trends, report findings, and recommend areas for improvement. The Specialist will also research and develop medical policies and procedures that are supported by national guidelines.
- RN/LPN with a valid New York State license required.
- CPC (Certified Professional Coder) required.
- Minimum one (1) year clinical experience required.
- Minimum two (2) years quality/utilization review experience in an HMO, managed care organization, or similar experience as a hospital inpatient coder or auditor.
- Ability to review health care delivery against established criteria is required.
- Experience with data retrieval, analysis, and case summarization is required Familiarity with statistics and clinical management/cost containment issues preferred.
- Demonstrated PC skills required.
- Knowledge of ICD-9 diagnosis and procedure codes, CPT codes, Revenue codes, HCPCS codes, DRG’s and RVU’s is required.
- Effective verbal and written communication skills are required.
- Ability to travel throughout CDPHP’s service area.
Salary Grade: 16
CDPHP - 21 months ago