Job Description
DPP is seeking a Business Analyst / Clinical Review Specialist for an opportunity in Columbia, SC.
Work arrangement:
75% Remote; up to 20% on-site required for in-person meetings
W2 position; 12+ months
Required certification:
Must have current, active, and non-restricted licensure by the State of South Carolina Board of Nursing as a Registered Nurse
Required education:
Bachelor of Science in Nursing (BSN) or Associate Degree in Nursing (ADN)
Position description:
The BA/Clinical Review Specialist performs medical record and claims review to ensure proper guidelines have been followed and medical necessity criteria has been met.
This project is a multi-year effort which primarily focuses on providing consulting services to operations and policy staff for the current MMIS.
The current position’s focus and priority is the continued support of serving as a subject matter expert (SME), building knowledge that allows policy and process owners to make the best recommendations for Medicaid members and providers.
A long-term plan includes participating and providing guidance in the administrative approach for the replacement Medicaid management system (RMMS). It is necessary to build and sustain a strong clinical staff who understand medical coding, medical necessity review, treatment, and determinations.
Responsibilities include, but are not limited to:
Review and interpret patient records and compares against criteria to determine medical necessity and appropriateness of care; determines if the medical record documentation supports the need for services.
Maintain a thorough knowledge of medical coding and collaborate with team members to share knowledge and adjust processes, as necessary to comply with requirements. Reviews and maintains knowledge of relevant SC Medicaid Policies and Procedures impacting claims approval processes.
Collaborate with other agency employees and external stakeholders, as necessary. Acts with proactive intent to improve claims related outcomes while considering input from team and making the best decisions to align with agency objectives and provider and member support.
Other project-related duties.
Required knowledge, skills, and abilities:
Current, active and non-restricted licensure by the state of South Carolina Board of Nursing as a Registered Nurse
2 years of healthcare experience that demonstrates expertise in conducting Utilization Reviews and/or Prior Authorization or related experience
1 year of experience working with IT developers/programmers in a payor environment
Knowledge of Medicare and/or Medicaid regulations. US Code and Code of Federal Regulations (CFR) regarding the Medicaid program
Medical record abstracting skills
Knowledge and experience in healthcare insurance payment methodologies
Claim processing testing experience in the healthcare industry (preferably Medicaid)
Strong knowledge of formal business process documentation.
Ability to effectively communicate with executive management, line management, project management, and team members.
Preferred KSAs:
Strong clinical assessment and critical thinking skills.
Knowledge of the organization of medical records, medical terminology, and disease process.
Excellent verbal and written communication skills.
Flexibility and strong organizational skills.
Proficiency in Microsoft Office and internet/web navigation.
Ability to work in a team environment.
Interested? Learn more:
Click the apply button or contact our recruiter Mason at (url removed) to learn more about this position (#(phone number removed).
DPP offers a range of compensation and benefits packages to our employees and their eligible dependents. Call today to learn more about working with DPP.
Authorized US Worker - US Citizens and those authorized to work in the US are encouraged to apply. We are unable to sponsor at this time. EOE/AA/V/D
Job Tags
Full time, Remote job,