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Supervisor, Clinical Chart Review

Company: Premier Healthcare Exchange, Inc.
Location: Bedminster
Posted on: June 12, 2021

Job Description:

POSITION OVERVIEW:

The Supervisor, Clinical Chart Review is primarily focused on supervising a team of nurses performing clinical reviews of facility claims, including UB's, Itemized Bills and also medical records to verify billing accuracy and clinical appropriateness. The Supervisor will be responsible for monitoring the Nurse Reviewer's performance to ensure savings are maximized and captured timely through proper claim handling. Effective and proven leadership experience is a must as recommendations to the Nurse Reviewer's regarding their claim management is required. Additionally, this role is responsible for providing daily team and operational support to the Director, Clinical Chart Review and the entire Hospital Bill Review leadership team.

KEY RESPONSIBILITIES:

  • Supervising a team of Nurse Reviewer's is required.
  • Monitoring Nurse Reviewer's work queues for timely and proper management of claims.
  • Ensure client turnaround times and specific processing guidelines are followed consistently.
  • Assess, track and report any delays in claim review or processing to the Director, Clinical Chart Review.
  • Make recommendations to the Nurse Reviewer's for process improvement and follow through for proper execution.
  • Perform quarterly Quality Assurance claim reviews and complete bi-annual assessment of Nurse Reviewer performance.
  • Continuous assessment of results at individual Nurse Reviewer level and make recommendations/changes to enhance outcomes.
  • Demonstrates understanding of provider billing nuances and service type trends to drive new ideas and recommend new approaches to the Clinical Chart Review team.
  • Evaluate current concepts and make recommendations to enhance "smart screening".
  • Research and implement third party tools/software, training and methodologies to ensure auditing success.
  • Evaluate, update and maintain the Standard Operating Procedures for the Clinical Chart Review team.
  • Collaboration with other members of the Hospital Bill Team
  • Partner with the Team lead to research new concepts and adjust workflows as needed.
  • Maintain awareness of and ensure adherence to Zelis standards regarding privacy

JOB REQUIREMENTS:

Technical Skills / Knowledge:

  • Demonstrates solid understanding of audit techniques, identification of revenue opportunities and financial negotiation with providers.
  • Ability to analyze and convert data to excel format and report trends necessary.
  • Proficiency in training techniques aimed at conveying subject matter expertise and scaling staff to maximize savings and revenue.
  • Computer proficiency and technical aptitude with the ability to utilize internal systems, EncoderPro, Micromedex, Milliman Care Guidelines, MS Office Suite and other audit software & tools.
  • Thorough knowledge of company and departmental policies and procedures.

Independence/ Accountability:

  • Strong leadership and team management experience required.
  • Requires minimal daily supervision.
  • Daily claim and performance review of the Clinical Chart Review team.
  • Ability to follow detailed instructions on new assignments.
  • Accountable to day to day tasks
  • Must have professional manner and respect the confidentiality of administrative matters and files.
  • Required to evaluate daily tasks and pivot as necessary to meet business needs.
  • Ability to manage and prioritize multiple tasks with the ability to adapt to meet departmental needs.
  • Ability to work under pressure and meet deadlines.

Problem Solving:

  • Makes logical suggestions as to likely causes of problems and independently recommends solutions.
  • Excellent organizational skills are required to prioritize responsibilities, thus completing work in a timely fashion.
  • Outstanding ability to multiplex tasks as required.
  • Excellent project and people management skills.
  • Attention to detail and concern for impact is essential.

Leadership Activities:

  • Provides guidance to lower level personnel.
  • Regularly attends meetings and leads training sessions as needed.
  • Must be proactive to ensure proper follow up and completion of projects.
  • Must maintain a professional demeanor in sensitive situations.
  • Assists other departments as necessary.

Communication Skills:

  • Must work well with others.
  • Effectively communicate with others by giving and receiving feedback.
  • Communicates ideas and information clearly.
  • Must have excellent communication and presentation skills to effectively interface with the entire staff, and external representatives from the business, financial, legal and scientific communities.

Business-related Travel:

  • Travel requirements to (primarily) domestic destinations should not exceed 10%.

PROFESSIONAL EXPERIENCE:

  • RN is required.
  • 5+ years of relevant experience or equivalent combination of education & work within healthcare payers.
  • Experience and working knowledge of Health Insurance, TPA's, Medicare guidelines and various healthcare programs.
  • Experience managing a team is required.
  • Experience with payment integrity is preferred.
  • Strong clinical skills to evaluate appropriate medical record review.
  • Demonstrates a proficiency in analyzing hospital claims and medical record documentation.
  • Demonstrated track record of success in managing key process improvement initiatives.
  • Industry experience implementing complex programs.
  • Experience managing internal relationships.
  • Excellent and professional verbal & written communication skills.

PHYSICAL DEMANDS:

  • Walking, standing and sitting.
  • Long periods of computer usage.
  • Handling - seizing, holding, grasping and fingering of objects, tools and controls.
  • Reaching.
  • Vision - close vision.
  • Hearing- ability to receive detailed information through oral and telephonic communication.
  • Ability to lift and move approximately thirty (30) pounds on a non-routine basis.
  • Ability to sit for extended periods of time.

WORK ENVIRONMENT:

  • A standard work week exists but with the understanding that additional time/effort outside of the usual parameters can/will occur based upon the overall needs of the integration, where deadlines exist and when necessary due to the needs of the integration team.
  • A standard business environment exists with moderate noise levels.

Zelis is a healthcare and financial technology growth company and market-leading provider of claims cost management and payments optimization solutions to price, pay and explain healthcare claims. Zelis delivers integrated network analytics, network solutions, payment integrity, electronic payments and claims communications for payers, healthcare providers and consumers in the medical, dental and workers' compensation markets nationwide. Zelis is backed by Parthenon Capital Partners and Bain Capital.

"We are an equal opportunity employer and all qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, disability status, protected veteran status, or any other characteristic protected by law."

Keywords: Premier Healthcare Exchange, Inc., Newark , Supervisor, Clinical Chart Review, Other , Bedminster, New Jersey

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