Facility Clinical Investigator – Registered Nurse – Mesa – On Time Talent Solutions

On Time Talent Solutions
July 14, 2019
Mesa, AZ
Job Type


Facility Clinical Investigator Responsibilities

  • Performs clinical coding review to ensure accuracy of medical coding and utilizes clinical expertise and judgment to determine correct coding and billing
  • Investigates, reviews, and provides clinical and/or coding expertise in the application of medical and reimbursement policies within the claim adjudication process through file review. This could include Medical Director / physician consultations, interpretation of state and federal mandates, applicable benefit language, medical and reimbursement policies and consideration of relevant clinical information
  • Performs clinical coverage review of claims, which requires interpretation of state and federal mandates, applicable benefit language, medical and reimbursement policies, coding requirements and consideration of relevant clinical information on claims with aberrant billing patterns
  • Identifies aberrant billing patterns and trends, evidence of fraud, waste or abuse, and recommends providers to be flagged for review
  • Maintains and manages daily case review assignments, with a high emphasis on quality
  • Provides clinical support and expertise to the other investigative and analytical areas
  • Will be working in a high volume production environment that is matrix drive
    Facility Clinical Investigator Requirements
  • Unrestricted RN (registered nurse)
  • Managed care and Healthcare claims experience
  • Investigation and/or auditing experience
  • Knowledge of health insurance business, industry terminology, and regulatory guidelines
  • 1+ year of medical coding experience
  • Must be competent in ICD - 10 and PCS
  • RHIT (registered health information technician), RHIA (registered health information administrator), CDIP (certified documentation improvement practitioner) OR current certified facility inpatient coder
  • 1+ year of DRG coding or DRG auditing experience (facility only)

Company Description

The competitive nature of hiring in today’s healthcare industry means innovation must occur in the way companies recruit top talent. At On Time Talent Solutions we put our 20+ year foundation of healthcare industry experience to work for you by understanding your unique needs and providing you with honest feedback to achieve your hiring goals.

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