Florida Blue

Job Description

The physician provides clinical support to the Payment Integrity Office (PIO) to ensure that fraud, waste, and abuse efforts are performed in accordance with the highest and most current clinical standards. Responsible to review cases and evaluate billing and coding accuracy, medical necessity and appropriateness of the treatment service. Responsible for appropriate application of Medical Policy and criteria for reviews, audits, and investigations. Provide necessary support to the anti-fraud program which involves conducting reviews of organization or functional activities related to alleged fraud, waste, and abuse perpetrated by providers, members, facilities, pharmacies, and /or groups.

Key Responsibilities

• Overall case guidance and consulting to ensure that fraud, waste, and abuse efforts are performed with the highest and most current clinical standards
• Apply health plan review hierarchy to member contracts, medical policy, clinical guidelines and other approved resources to render timely decisions on services provided to members
• Perform reviews and participate in peer-to-peer discussions of inpatient DRG Clinical Validation audits and appeals
• Serves as a resource for information and consultation on the issues related to utilization management and clinical services
• Approval and direction of consultant reviews. Participation in and support of overpayment recoveries
• Support as needed to internal and external agencies in conjunction with these reviews such as but not limited to the Special Investigations Unit
• Review of services suspected of being performed for purposes not medically necessary. Appropriate documentation of decisions and follow-up
• Comply with all state, federal, and regulatory requirements
• Other duties as necessary to ensure progression and completion of reviews
• Participate on projects and committees as necessary
  
  

Key Requirements

• MD or DO with an unrestricted FL medical license
• 3+ years of experience in active clinical practice (primary care specialty desirable)
• Excellent written and verbal communication skills with the ability to interact with all levels of the organization, external customers and providers
• Ability to analyze data, measure outcomes, and develop action plans
• Ability to intervene in crisis situations and multi-task
• Conversant with most areas of medicine, show ability for rapid, accurate decision-making, and enjoy care review and the investigation and resolution of complex issues. Experience with CPT coding, medical claims review, hospital billing, and reimbursement.
• Experience in utilization management, case review, and/or quality improvement activities in a managed care setting.
  
  

Preferred

• Board Certification in an American Board of Medical Specialties or Bureau of Osteopathic Specialist recognized specialty, or The National Board of Physicians and Surgeons (NBPS)
• Nationally recognized Certification in Inpatient and Outpatient coding, e.g., AHIMA and AAPC credentials
• Graduate degree such as a MBA or MPH
• Certified Physician Executive (CPE)
• American Board of Quality Assurance and Utilization Review Physicians (ABQAURP)
  
  

General Physical Demands

Sedentary work: Exerting up to 10 pounds of force occasionally to move objects. Jobs are sedentary if traversing activities are required only occasionally.

What We Offer

As a Florida Blue employee, you will thrive in our Be Well, Work Well, GuideWell culture where being well as an individual, and working well as a team, are both important in serving our members and communities.

To support your wellbeing, comprehensive benefits are offered. As an employee, you will have access to:

Medical, dental, vision, life and global travel health insurance;

Income protection benefits: life insurance, short- and long-term disability programs;

Leave programs to support personal circumstances;

Retirement Savings Plan including employer match;

Paid time off, volunteer time off, 10 holidays and 2 well-being days;

Additional voluntary benefits available; and

A comprehensive wellness program

Employee benefits are designed to align with federal and state employment laws. Benefits may vary based on the state in which work is performed. Benefits for intern, part-time and seasonal employees may differ.

To support your financial wellbeing, we offer competitive pay as well as opportunities for incentive or commission compensation. We also conduct regular annual reviews with pay for performance considerations for base pay increases.

Annualized Salary Range: $224,000 - $364,000

Typical Annualized Hiring Range: $224,000 - $280,000

Final pay will be determined with consideration of market competitiveness, internal equity, and the job-related knowledge, skills, training, and experience you bring.

We are an Equal Employment Opportunity employer committed to cultivating a work experience where everyone feels like they belong and can perform at their best in pursuit of our mission. All qualified applicants will receive consideration for employment.