Healthcare Fraud Shield’s suite of FWA products introduces several new technology applications. The FWAShield™ platform satisfies a long-standing demand for pre-payment solution with its paradigm shifting product – PreShield™. In combination, Healthcare Fraud Shield utilizes the same ground breaking technology to deliver PostShield™ and RxShield™ - the most prolific post-pay system in existence today. We anchor these cutting edge platforms with the most forward thinking fully integrated claim management system - CaseShield™ and an advanced ad-hoc querying tool - QueryShield™. Utilized on a standalone basis or together, these solutions guarantee a dramatic reduction in costs, improved efficiency, and overall increase in ROI.
Healthcare Fraud Shield is seeking an experienced Senior SIU Clinical Reviewer who can perform the following duties:
•Train newly hired Clinical Investigators on Clinical Investigative Processes and Protocols •Conduct first level quality checks on clinical reviews •Provide updates to SIU Manager as needed •Work with SIU Team (Clinical Reviewers, CPCs, Investigators, Analysts-including performing quality check on work, assisting in research, discuss to make appropriate coding determinations as needed) •Analyze and interpret patient medical records pertaining to FWA investigations as needed •Compare to information submitted on the claims in order to determine amount and nature of billable services as needed •Determines appropriateness of billing and reimbursement as needed •Documents findings for each claim line in a spreadsheet as needed •Summarize findings in a written report as needed •Abstracts CPT, HCPCS, Revenue Codes, DRG codes, and ICD-9/ICD-10 from medical records as needed •Responsible for maintaining current knowledge of coding guidelines and relevant federal and/or state regulations as needed •Perform data analysis of client data as needed •Conduct various aspects of FWA investigations as needed •Provide Subject Matter Expertise and SIU support to clients as needed •Comply with Privacy and Security standards •Understands and complies with all company Privacy and Security standards •Employee may not use or disclose any protected health information, except as otherwise permitted, or required, by law. •Other duties as needed.
KNOWLEDGE, SKILLS, & ABILITIES
•Knowledge of medical terminology •Knowledge of coding including CPT, HCPCS, Revenue Codes, DRG Codes, and ICD-10. •Knowledge of specialty medical practices. •Must be detail-oriented. •Ability to communicate effectively both verbally and in writing. •Strong listening skills. •Independent. •Responsible. •Self-disciplined. •Ability to meet defined performance and production goals. •Strong computer skills. •This job requires access to confidential and sensitive information, requiring ongoing discretion and secure information management.
•Certified Professional Coder - (CPC®) through governing body AAPC •Registered Nurse (RN) •Minimum of five years of healthcare fraud experience.
Telecommuting is allowed.
About Healthcare Fraud Shield
Healthcare Fraud Shield is a provider of dynamic fraud, waste and abuse detection software solutions that have dominated the complex financial services industry over the past fifteen years. Our new suite of products introduce several new technology applications to the healthcare industry that will revolutionize cost reduction opportunities. Healthcare Fraud Shield offers a fully integrated platform called FWAShield™ that includes 360ProReport™ (a focused provider search), PreShield™ (pre-payment), PostShield™ (post-payment), RXShield™ (pharmacy), QueryShield™, (ad-hoc querying tool) and CaseShield™ (case management). Healthcare Fraud Shield also offers a variety of SIU Services from leading industry experts.
These solutions may be utilized on a standalone basis or together, guaranteeing a dramatic reduction in customer's healthcare costs as well as large improvements in overall ROI.