Briljent is seeking an experienced Clinical Reviewer to Support the Medicaid Fraud Waste and Abuse Detection Services project.

Responsibilities:

• Performs medical record reviews to determine the quality of care, identifies quality issues, and compliance with regulations and standards instituted by the Indiana Health Coverage Programs, Centers for Medicare & Medicaid Services, American Medical Association, as well as other applicable standards.
• Monitors the progress of each medical review case within the case tracking system and ensures that appropriate actions are taken
• Conducts medical record reviews or compliance reviews independently and submits preliminary findings to the Lead Clinical Reviewer.
• Prepares the draft audit findings, administrative reconsideration, and final audit findings reports for medical reviews conducted and escalates for Lead Clinical Reviewer approval.
• Prepare medical record review workpapers detailing the procedures performed, supporting documentation obtained and conclusions reached to support audit findings.
• Assists with the appeals process as necessary.
• Ensure appropriate outcomes; practice and adhere to state, federal, and national guidelines.
• Stay abreast to changes in clinical guidelines, state and federal policies and regulations.
• Research Indiana Medicaid rules and regulations and update repository with new bulletins, policies, and procedures

• Bachelor's Degree required
• Licensed Practical Nurse (LPN) or Registered Nurse (RN) license and/or coding certification (e.g., CCS, CPC)
• At least one (1) year of Medicaid experience or exposure as a clinician or clinical reviewer
• A minimum of one year nursing experience, clinical experience preferred.
• Knowledge of CPT coding guidelines and ICD-10 diagnosing standards
• Proficiency in Microsoft Office: Excel, Word, Outlook
• Ability to work in a fast-paced environment.
• Must have strong analytical and problem-solving skills.
• Ability to work well as a member of a team or alone.
• Skilled technical and business writer
• Experience working collaboratively with healthcare providers is strongly preferred
• Knowledge or experience with health care claims data and healthcare fraud, waste, and abuse

Physical Requirements & Environmental Conditions

These physical demands must be met by an employee to successfully perform the essential functions of this job. Employee is regularly required to communicate, remain in a stationary position, and utilize technology tools such as a laptop computer for extended periods of time. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

Equal Opportunity Employer

Briljent is a solutions-based company. Solutions come from creative ideas; ideas come from being creative with differences. Briljent believes diversity and inclusion are critical to the success of the company. Employment at Briljent is based on merit and professional qualifications. We do not discriminate against any employee or applicant because of race, creed, color, religion, gender, sexual orientation, gender identity/expression, national origin, disability, age, veteran status, marital status or any other basis protected by federal, state or local law, regulation or ordinance.