The Assistant Medical Review Manager supports the Centers for Medicare and Medicaid Services (CMS) by identifying improper payments made under Medicaid and the Children's Health Insurance Program (CHIP). This position utilizes a medical review background to increase efficiencies in the Federal government by conducting in-depth reviews of fee-for service (FFS), and eligibility records, and then produces error rates based on the reviews. Under the direction of the Medical Review Manager, supervises day-to-day operations, provides developmental feedback, training and direction to nursing staff in addition to conducting reviews for the purpose of ensuring the accuracy and quality of nurse review.
ESSENTIAL DUTIES AND RESPONSIBILITIES
Essential duties and responsibilities include the following. Other duties may be assigned.
Responsible for the integration of CNI Core Competencies into daily functions, including: commitment to integrity, knowledge / quality of work, supporting financial goals of the company, initiative / motivation, cooperation / relationships, problem analysis / discretion, accomplishing goals through organization, positive oral / written communication skills, leadership abilities, commitment to Affirmative Action, reliability / dependability, flexibility and ownership / accountability of actions taken.
Assists Medical Review Manager with day-to-day supervision of nursing staff including employee relations, performance management and staff development. Manages time and attendance and reviews and approves paid time off. Eliminates operating issues, assists with problem resolution and is the first level of escalation for service difficulties.
Assists the Medical Review Manager with planning, organizing, and directing review staff activities to ensure compliance with established federal and state regulations and timely completion.
Ensures that directives and requirements are clearly understood by employees and contributes to the organization achieving its goals.
Conducts daily quality control audits of nursing staff, verifying accuracy, completeness and medical necessity.
Directs staff to correct identified errors. Instructs staff on error correction and appropriate documentation write-ups.
Assist with training for all new nursing and coding staff, answers review and coding questions from staff and provides additional instruction as needed to maintain competency of staff. Assists with developing educational materials for the nursing staff.
Monitors workflow, track metrics, and supports the team by completing Level 1, Level 2 , Inter-rater Reliability (IRR) and Quality Control (QC) reviews.
Approves additional documentation request from the nursing staff.
Reviews and approves Level 1 and Level 2 error findings.
Assist with reviewing and processing of difference resolutions.
Evaluates, edits and approves state questionnaires.
Executes category changes for claims that need to be moved to a different category.
Provides clarification of required documentation improvement. Validates additional documentation request for necessity and accuracy.
Assists with nursing appeals as required. Provides supporting information and supplemental data as needed to achieve desired outcome.
Assists Medical Review Manager in personnel issues including interviews, hire recommendations, development, training, evaluation of performance and, when necessary, discipline and discharge of subordinate personnel.
Other duties may be assigned.
Responsible for aiding in own self-development by being available and receptive to any training made available by the company.
Plans daily activities within the guidelines of company policy, job description and supervisor's instruction in such a way as to maximize output.
Responsible for keeping own immediate work area in a neat and orderly condition to ensure safety of self and coworkers. Will report any unsafe conditions and/or practices to the appropriate supervisor and Human Resources. Will immediately correct any unsafe conditions as the best of own ability.
Associate’s degree in Nursing and a minimum of five (5) years relevant experience, or equivalent combination of education / experience. Experience in medical/utilization review and/or clinical documentation. Experience with Medicaid and/or CHIP at a state or national level required, particularly the coverage and payment rules required.
JOB SPECIFIC KNOWLEDGE / SKILLS / ABILITIES
Working knowledge of standardized medical review criteria
Working knowledge applying coding guidelines for medical review of Medicaid related services, including Current Procedural Terminology (CPT) codes, International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) codes, and Healthcare Common Procedure Coding System (HCPCS) Codes
Knowledge and understanding of medical coding and reimbursement guidelines
Attention to detail and completeness with a thorough understanding of government rules and regulations, and potential areas of risk for fraud
Ability to create effective training sessions using a wide variety of proven training methods and mediums, which includes interactive methods of feedback
Ability to command and conduct training sessions in a classroom setting with enthusiasm and clarity
Ability to handle multiple projects and appropriately prioritize tasks to meet deadlines
Excellent computer skills with proficiency using Microsoft Office (i.e., Outlook, Word, Excel, PowerPoint, etc.)
Exceptional skills in researching, writing, reviewing and editing technical training materials and methods
Excellent verbal and written communications skills
Excellent interpersonal relations skills with ability to effectively interact with others in the performance of assigned duties and with all levels of personnel from line level to senior leaders
Excellent customer service skills with ability to maintain positive working and professional relationships
Solid problem-solving skills with ability to identify and resolve issues in a timely manner
Ability to be self-directed and proactive in work activities
Ability to work both individually and in a team environment
CERTIFICATES, LICENSES, REGISTRATION
Medical coders shall maintain the required continuing education hours in order to maintain current and proper national certification(s) requirements for this position at no expense to the government. The following are recognized professional certifications:
Registered Health Information Technician (RHIT)
Registered Health Information Administrator (RHIA)
Certified Professional Medical Auditor (CPMA)
Certified Professional Coder (CPC)
Certified Professional Coder, Hospital (CPC-H)
Certified Coding Specialist (CCS)
Certified Coding Specialist – Physician (CCS-P)
Ability to read, analyze, and interpret general business periodicals, professional journals, technical procedures, or governmental regulations. Ability to write reports, business correspondence, and procedure manuals. Ability to effectively present information and respond to questions from groups of managers, clients, customers, and the general public.
Ability to add, subtract, multiply, and divide in all units of measure, using whole numbers, common fractions, and decimals. Ability to compute rate, ratio, and percent and to draw and interpret bar graphs.
Ability to define problems, collect data, establish facts, and draw valid conclusions. Ability to interpret an extensive variety of technical instructions in mathematical or diagram form and deal with several abstract and concrete variables.
Work Environment / Physical Requirements
The work is primarily sedentary. Requirements may include prolonged walking, standing, sitting, or bending. Carrying or lifting of medical records or documentation may be required daily. Use of one or more computer programs and monitors simultaneously is typical and frequent. Routine 45% of travel between the Hub facility and the assigned remote sites is required.