Integrity Clinical Readmission Manager

Job Description A bit about this role:
The Clinical Readmission Manager is responsible for conducting prepayment and post-payment clinical reviews of inpatient hospital admissions and subsequent admissions to the same or a related hospital within 30 days of the prior discharge date. The auditor reviews claims and medical records for both admissions to determine whether the readmission is clinically related to the prior admission and/or potentially preventable under applicable organizational, regulatory, and Payment Integrity guidelines.

This role requires strong inpatient clinical knowledge, sound clinical judgment, and experience reviewing hospital records and readmission cases. The Clinical Readmission Auditor is responsible for producing accurate, timely, objective, and defensible clinical determinations and supporting documentation. The auditor also prepares initial findings, dispute responses, and appeal documentation related to readmission reviews.

• Conduct Clinical Reviews:
  Perform prepayment and post-payment clinical reviews of inpatient admissions and related readmissions occurring within 30 days of a prior discharge. Review applicable claims and medical records to assess the clinical relationship and potential consolidation of the readmission.
• Apply Review Guidelines:
  Apply established organizational policies, regulatory requirements, readmission criteria, and applicable exclusions consistently when evaluating cases.
• Document Determinations:
  Prepare clear, objective, timely, and defensible clinical rationales and supporting documentation for review findings.
• Support Disputes and Appeals:
  Prepare initial findings, dispute responses, and appeal letters, and review additional documentation submitted during the dispute or appeal process.
• Collaborate on Complex Reviews:
  Partner with Payment Integrity, appeals, quality, utilization management, and other internal teams to address complex, escalated, or disputed cases.
• Promote Quality and Consistency:
  Participate in calibration sessions, peer reviews, quality reviews, and case discussions to support accurate and consistent review outcomes.
• Maintain Compliance and Documentation:
  Maintain accurate records in applicable clinical review and audit systems while protecting confidential patient, member, and provider information.
• Support Continuous Improvement:
  Identify trends, documentation concerns, and opportunities to improve readmission review processes and outcomes.

• Licensure:
  Registered Nurse degree with a current, active, and unrestricted RN license in at least one U.S. state. A multistate license is not required.
• Relevant
  
  Experience:
  
  Five or more years of experience in clinical nursing, hospital-based care, healthcare audit, Payment Integrity, utilization management, quality review, or a related healthcare environment, including demonstrated experience reviewing inpatient hospital readmissions.
• Clinical Expertise:
  Strong knowledge of inpatient clinical care, disease processes, complications of care, discharge planning, and transitions of care. Ability to evaluate whether admissions are clinically related and/or potentially preventable.
• Medical Record Review:
  Experience reviewing medical records and synthesizing clinical information from multiple sources, including the ability to identify clinical, documentation, discharge planning, follow-up, and care coordination factors that may contribute to a readmission.
• Audit and Determination
  
  Skills:
  
  Experience applying established clinical criteria, policies, regulatory guidance, and review methodologies. Ability to exercise sound clinical judgment and prepare clear, concise, objective, and defensible clinical rationales,…