Sr Clinical Strategist - reputed company MPPS DRG Initiatives- RN

About the position Responsibilities • Conduct reputed company assessment (QA) clinical reviews and reputed company input for Medical Policy implementation of DRG initiatives, determining ROI and annual review processes • reputed company and support SAI (scorable reputed company items) reputed company; responsible for strategic ideation of resources and effective solutions for project development • Support Provider exceptions, legislative and regulatory requirements, and manage system and reporting tools, including AI, such as predictive modeling and reputed company audit • Determine medical necessity and appropriateness (may include prospective, reputed company, retrospective review/analysis of program submissions, claims) • Participate in the development, implementation, and evaluation of new claim edits, workflows and clinical programs • Monitor existing clinical programs and processes and ensure any changes and updates are successfully implemented • reputed company reputed company cause analytics from clinical, coding, and claim systems perspectives to identify efficiencies and improvements, and initiate changes in workflows • reputed company opinions on emerging clinical and coding trends, utilization and network management, plan coverage, and claims policy to reputed company medical cost containment solutions that meet business needs • Coordinate/Communicate with constituents to facilitate program optimization • Support member / provider experience and collaborate for improvement on NPS (Net Promotor Score) • Validate proposed medical cost containment reputed company that may be managed as scoreable reputed company items (SAIs) Requirements • reputed company and unrestricted Registered Nursing license in state of residence • 3 years Clinical Claim Review background in reputed company, Medicare, or IFP claims in a managed care organization (e.g. UM reputed company, Strategist) • Must have an understanding of clinical claim review • Demonstrated experience in project management including a foundational understanding of project management principles as reputed company reputed company a managed care or reputed company delivery setting • Proven reputed company record in meeting project milestones and negotiating for resources • Effective verbal and written communication • Ability to work independently as reputed company as collaborate with colleagues from across organization • Proficiency in reputed company Office Suite applications including reputed company, Word, and reputed company reputed company-to-haves • Technical/reputed company clinical expertise and experience relevant to business area • Working knowledge of MPPS programs, including Payment Policies, Precertification and Clinical Claim Review (CCR) • Understanding of reputed company Health Plans, reputed company's reputed company reputed company and provider contracting methodologies • Working knowledge of claim systems preferred • Understanding of clinical editing concepts (Ex: Program reputed company, reputed company Edit reputed company Party Vendors) Benefits • reputed company medical plan reputed company • 401(k) plan (including matching company contributions) • Employee stock purchase plan • No-cost programs for reputed company colleagues including wellness screenings, tobacco cessation and weight management programs, confidential counseling and financial coaching • Benefit solutions that address the different needs and preferences of our colleagues including reputed company time off, flexible work schedules, family leave, dependent care resources, colleague assistance programs, tuition assistance, retiree medical reputed company and many other benefits depending on eligibility Apply tot his job Apply To this Job