Responsible for assisting and supporting in the evaluation, recommendation, establishment, implementation and analysis of new and improved production workflows, work processes for systems, reporting, and new products/programs to improve customer service levels and overall quality. * Review of medical records * Perform clinical reviews with knowledge of body systems, anatomy and physiology. * Assist and support in the planning, coordination, developing and implementing of approved audit programs to enhance the overall efficiency of operational procedures, methods, controls and performance. * Analyze, process and/or expedite operational transactions; this may include timely resolutions of problems. * Participate in systems testing, develop procedures and controls and provide recommendations for the ongoing improvement of the updated process. * Provide leadership team with status of projects, issue, communicate and recommend policy decisions to achieve project objectives. * Utilize and maintain available corporate production and reporting systems; produce routine and non-routine reports, presentations, letters, communications and graphics. * Assist internal and external personnel by answering questions and supplying information. * Develop and maintain effective working relationships with customers and partners. * Conduct and oversee training of current and new staff. * Review letters and reports of audit staff for accuracy and completeness. * Complete special assignments and projects as assigned. * Serve as back up to Team Leader as needed. QUALIFICATIONS * Bachelor's degree in health-related field preferred. * Four (4) years of experience in related field. * Experience required in operational analysis, data analysis and problem resolution type activities. * Current unrestricted state of Michigan Registered Nurse license required. * Current Registered Health Information Administrator or Registered Health Information Technician for coding responsibility. * Current Certified Pharmacy Technician for pharmacy audit responsibility. * Thorough understanding of medical coding (CPT-4; HCPCS; ICD-9 or DRG) as it relates to audits. * Ability to plan, organize direct and control projects. * Excellent written and verbal communication skills. * Ability to lead and contribute to process improvement projects. * Working knowledge of PC applications and/or mainframe preferred. * Other related skills and/or abilities may be required to perform this job. Departmental Qualifications: * Knowledge of Interqual criteria is preferred.
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