Payment Integrity Clinical Readmission Manager
Core
Conduct prepayment and post-payment clinical reviews of inpatient hospital admissions and readmissions to determine clinical relationship and preventability under regulatory guidelines.
Role type
Senior clinical auditor (nursing)
Builds
Defensible clinical determinations, dispute responses, and appeal documentation for payment integrity reviews.
Domain
Healthcare payment integrity and clinical audit
Required skills
Registered Nurse (RN) licensure, inpatient clinical care knowledge, medical record review, clinical criteria application, regulatory compliance, analytical problem-solving, electronic medical records proficiency
Preferred skills
Medicare/Medicaid payer criteria experience, dispute/appeal handling, process improvement, care transition expertise, automation/AI familiarity
Technologies
Electronic medical records, claims information systems, clinical review platforms, audit workflow platforms
Responsibilities
Perform clinical reviews of admissions and readmissions, apply review guidelines and policies, document clinical rationales, support disputes and appeals, collaborate on complex cases, participate in quality calibration, maintain compliance records
Seniority
Senior, hands-on IC