Medicaid Medical Review SME

Booz Allen Hamilton•Baltimore, MD

2d•Remote

About The Position

As the Medicaid Medical Review SME, you will be in direct communication with the Medical Review Manager, Medical Reviewers, and client staff to provide expert clinical guidance and technical assistance, ensuring adherence to the Medical Review requirements. You will utilize extensive knowledge and proven ability to continually assess and evaluate clinical compliance with relevant regulations, both at a state and federal level. You will also be responsible for developing innovative solutions to complex problems. You’ll work without considerable direction and mentor and may supervise team members. Join us. The world can’t wait.

Requirements

3+ years of experience practicing as a licensed Registered Nurse
3+ years of experience in a supervisory or managerial role in the health insurance industry, a utilization review firm, or health care claims processing organization, including performing medical and coding reviews of multiple medical and surgical claims from multiple provider types
Experience performing MR, utilization, or QA reviews
Knowledge of state and federal healthcare regulations, policies, coverage guidelines, and reimbursement rules in making clinical determinations as to the medical necessity and appropriateness of services rendered and billed and corresponding payment determinations
Knowledge of the Medicaid or CHIP program, including the coverage, conditions of payments, and state-specific policy requirements for health care coverage and payment
Ability to obtain and maintain a Public Trust or Suitability/Fitness determination based on client requirements
Bachelor's degree
Ability to obtain a Coding Certification such as CPC Certification within 12 months of hire date
Registered Nurse License

Responsibilities

Provide expert clinical guidance and technical assistance to the Medical Review Manager, Medical Reviewers, and client staff.
Ensure adherence to Medical Review requirements.
Continually assess and evaluate clinical compliance with relevant state and federal regulations.
Develop innovative solutions to complex problems.
Work without considerable direction.
Mentor and potentially supervise team members.