Program Integrity Clinical Reviewer II, Readmission Experience Preferred

CareSource

Clinical Reviewer in Program Integrity reviewing medical records and claims accuracy. Collaborating on audits, conducting meetings with Medical Directors and developing audit tools and education plans.

Posted 5/15/2026full-timeRemote • 🇺🇸 United StatesMid-LevelSenior💰 $72,200 - $115,500 per yearWebsite

About the role

Key responsibilities & impact

Conduct claim reviews against medical records to determine claim accuracy for claims payment
Conduct meetings to present identified clinical issues and associated research to Medical Directors and physician experts for validation
Conduct, participate or contribute to on-site audits and investigations of medical professionals, subcontractors, and contracted entities
Assist the audit and investigative teams in the development of clinical and coding based audit tools
Draft proposed provider education and formal corrective action plans for clinical and coding deficiencies
Collaborate with other departments including Pharmacy, Medical Management, Provider Relations, Claims, Contracting, Case Management and Legal
Responsible for maintaining confidentiality of all sensitive investigative information
Develop and maintain SIU specific clinical and investigative training materials to include processes (SOPs)

Requirements

What you’ll need

Bachelor of Science Degree or equivalent experience required
Minimum of five (5) years clinical practice experience required
Significant experience auditing medical records against claims is required
Prior Fraud, Waste, Abuse (FWA) investigation and auditing experience preferred
Medical research experience is preferred
CPT, HCPCS and ICD-10 coding knowledge is required
Knowledge of Medicare/Medicaid/Managed Care preferred
Proficient with Microsoft Office Word, Excel and PowerPoint
Excellent written and verbal communication skills with adeptness to create, present and evaluate teaching materials

Benefits

Comp & perks

Health insurance
Retirement plans
Paid time off
Flexible work arrangements
Professional development opportunities

ATS Keywords

✓ Tailor your resume

Applicant Tracking System Keywords

Tip: use these terms in your resume and cover letter to boost ATS matches.

Hard Skills & Tools

clinical practiceauditingmedical record reviewCPT codingHCPCS codingICD-10 codingFraud, Waste, Abuse investigationclinical audit toolsprovider educationcorrective action plans

Soft Skills

communication skillspresentation skillscollaborationconfidentialitytraining developmentresearch skillsanalytical skillsproblem-solvinginterpersonal skillsorganizational skills

Certifications

Bachelor of Science Degree