Payment Integrity Clinical System Consultant- Work at home

Published date Posted on Indeed on Nov 24, 2021 (6 d ago)

Imagine a workplace that encourages you to interpret, innovate and inspire. Our employees do just that by helping healthcare payers manage the cost of care, improve competitiveness and inspire positive change. You can be part of an established company with a 40-year legacy that helps our customers thrive by interpreting our client's needs and tailoring innovative healthcare cost management solutions.
Our commitment to diversity, inclusion and belonging are part of the fabric of our company. We strive to create a workplace that fosters mutual respect and collaboration, where every talent individual can participate and perform their best work. We are MultiPlan and we are where bright people come to shine!
JOB SUMMARY: This position is responsible for helping to identify coding and other health care claim deviations that indicate a physician, hospital or other provider may not have properly billed for a health care service. The incumbent will create requirements to build on a software application. Requirements will stem from experience and knowledge in clinical and coding work. The incumbent will need to effectively communicate with peers within and outside of the department about coding research, claims issues and the software requirements they are working on.
The incumbent in Clinical Systems Consultant position must meet the job requirements and should be able to perform the roles and responsibilities of the Clinical Systems Analyst, in addition to those outlined in this job description.
JOB ROLES AND RESPONSIBILITIES:
1. Identify, research and document a broad variety of medical claims coding/clinical and reimbursement topics. Construct research papers around these topics and create presentations to explain research topics to peers within and outside of the department.
2. Create effective software application requirements that encompass a multitude of coding/clinical research topics.
3. Utilize claims data mining tools to aid in creating software application requirements including interpreting claims data and applying various aggregations of data to modify or test design of software application requirements. Develop/recognize new ways to look at data and give instructions to analysts and developers on how to query data.
4. Apply table driven system logic and pre-defined advanced query logic to create software application requirement. Identify system bugs and design enhancements needs and provide research support to developers.
5. Act as a mentor and/or provide supervision to more junior team members on a variety of topics.
6. Deliver effective Peer Quality Assurance (QA) feedback on a variety of coding/clinical concepts, research papers and all factors including; identifying gaps in research and advising on changes to factor language and system logic, and recommending when more advance software capabilities could be incorporated.
7. Lead assigned projects & functions above daily work.
8. Demonstrate an understanding of the majority of topics covered in the MARS system, as well as content and system principals that lay the foundation and guide development.
9. Manage and maintain compliance of the teams work in accordance with the departmental release cycle.
10. Collaborate, coordinate, and communicate across disciplines and departments.
11. Ensure compliance with HIPAA regulations and requirements.
12. Demonstrate Company's Core Competencies and values held within.
13. Please note due to the exposure of PHI sensitive data - this role is considered to be a High Risk Role.
14. The position responsibilities outlined above are in no way to be construed as all encompassing. Other duties, responsibilities, and qualifications may be required and/or assigned as necessary.
JOB SCOPE:
This position works independently with minimal supervision to complete the outlined job responsibilities. This is a research position that involves varied and complex work. Must be able to interpret and translate research into software application requirements independently. A variety of research topics will be provided and the incumbent needs to be able to appropriately determine the scope of the topics and how they fit in with existing requirements. The incumbent will have the authority to determine priorities of research work assigned to the team. This position requires creativity and expert problem solving skills to complete the responsibilities as assigned. The incumbent uses knowledge of the Company's general business principles, industry dynamics, market trends, and specific operational details when performing all aspects of the position.

JOB REQUIREMENTS (Education, Experience, and Training):

  • Min. Associates degree + 10 years, OR 12 years in a clinically related field including but not limited to; coding, nursing, radiology, laboratory, pharmacy, physician assistant.
  • Preferably with expertise in at least four coding/clinical specialties, or 10+ years in a single specialty
  • Preferred experience in at least one of the following; auditing of team members, auditing of external providers, responding to claim denials, claims data mining, QA of coding work, health plan policy creation, health plan claims editing, utilization management.
  • Must possess an active applicable related certificate or license
  • Exhibit advanced proficiency in Microsoft Excel.
  • Exhibit an understanding of relationships between database tables, methods of aggregating data. Able to converse with developers on database structure and programs such as Microsoft Access or SQL.
  • Individual must be comfortable researching highly-technical information on the internet. Familiarity with medical coding sources such as CPT Assistant, medical association publications supporting medical coding and clinical research websites is expected.
  • Display a strong understanding of human anatomy and medical terminology.
  • Extensive knowledge of claims data and associated industry-standard codes such as CPT, ICD diagnosis, revenue, bill type and admit/discharge status codes.
  • Must be extremely detail-oriented.
  • Possess strong writing and verbal communication and be able to translate difficult clinical concepts into easier-to-understand language for non-clinical readers.
  • Individual in this position must be able to work in a standard office environment which requires sitting and viewing monitor(s) for extended periods of time, operating standard office equipment such as, but not limited to, a keyboard, copier and telephone.

We realize that our employees are instrumental to our success, and we reward them accordingly with very competitive compensation and benefits packages, an incentive bonus program, as well as recognition and awards programs. Our work environment is friendly and supportive, and we offer flexible schedules whenever possible, as well as a wide range of live and web-based professional development and educational programs to prepare you for advancement opportunities.
Your benefits will include:

  • Medical, dental and vision coverage (low copay & deductible
  • Life insurance
  • Short and long-term disability
  • 401(k) + match
  • Generous Paid Time Off
  • Paid company holidays
  • Tuition reimbursement
  • Flexible Spending Account
  • Employee Assistance Program
  • Summer Hours

EEO STATEMENT
MultiPlan is an Equal Opportunity Employer and complies with all applicable laws and regulations. Qualified applicants will receive consideration for employment without regard to age, race, color, religion, gender, sexual orientation, gender identity, national origin, disability or protected veteran status. If you'd like more information on your EEO rights under the law, please click here.

Job Type: Full-time


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Imagine a workplace that encourages you to interpret, innovate and inspire. Our employees do just that by helping healthcare payers manage the cost of care, improve competitiveness and inspire positive change. You can be part of an established company with a 40-year legacy that h