Medical Review Claims Analyst II
About The Position
CoventBridge Integrity Systems is hiring a remote Medicare Medical Review Claims Analyst II/Appeals Coordinator. The position is responsible for organizing and conducting entry-level reviews of Medicare and Medicaid claims, repricing claims, and calculating overpayments for completed post-payment Medical Review cases. It also handles repricing needed during appeals and supports Medical Review during fraud investigations and other program-integrity initiatives, including requests for information. The analyst applies medical terminology and coding knowledge to claim repricing and payment work. Other duties include entering information into databases, scanning and filing documents, and assisting with reporting. The role requires adherence to confidentiality and security guidelines for PHI and HIPAA-protected information, as well as applicable Program Integrity Manual, Statement of Work, and CMS requirements.
Requirements
- No adverse actions may be pending or have been taken against the applicant by a State or Federal licensing board or program; no conflict of interest as defined in § 1154(b)(1) of the Social Security Act.
- Maintain a valid driver’s license for the state of residence.
- Extensive knowledge of medical terminology and coding principles.
- Knowledge of Medicare guidelines and coverage.
- Ability to read paper and electronic Medicare and Medicaid claims and basic knowledge of Medicare claims systems.
- Working knowledge of Medicare claims pricing and payment systems and Medicaid pricing and enhanced rates for states.
- Excellent oral and written communication skills.
- Ability to work independently with minimal supervision.
- Ability to work in an MS Office environment.
- Extensive knowledge of medical terminology and experience analyzing and processing Medicare claims, as well as experience related to the specific workload of the assigned task order.
- At least one year of experience in medical terminology and Medicare claims payment systems or Medicaid claims, or CPC certification.
- High school diploma.
Nice To Haves
- Two-year degree with a healthcare emphasis.
- Certified Professional Coder (CPC) certification.
Responsibilities
- Maintain workflow balance and accurately complete repricing requests within established departmental timeframes.
- Use knowledge of medical terminology and coding principles to reprice claims.
- Complete assignments that meet or exceed quality-assurance accuracy goals.
- Implement, terminate, and track prepayment edits daily.
- Prepare monthly prepayment savings reports on time.
- Move claims to UPIC safe locations when medical records are received for prepayment claims.
- Adjudicate DME prepayment claim decisions in VMS.
- Facilitate daily adjudication of prepayment claims based on Medical Review decisions.
- Scan and file Medical Review records and other documents as needed.
- Enter information into databases and Excel spreadsheets as needed.
- Follow confidentiality and security guidelines regarding PHI and HIPAA-protected information.
- Perform other assigned duties that support UPIC goals and objectives and comply with applicable program and CMS requirements.
Benefits
- Medical, dental, and vision plans.
- Employer-paid life, LTD, and STD coverage.
- 401(k) with company match up to 4%.
- Paid time off and company-paid holidays.
- Tuition assistance after one year of service.
Stand Out From the Crowd
Upload your resume and get instant feedback on how well it matches this job.
What This Job Offers
Job Type
Full-time
Career Level
Entry Level
Education Level
High school or GED
