Medical Reviewer III (Medicare/DME)

Empower AI Inc.

About The Position

Empower AI is looking for a casual Medical Review Specialist III (Medical Reviewer III) to perform Medicare comprehensive medical record and claims review to make payment determinations for Medicare Durable Medical Equipment (DME). This role is a critical component in meeting the mission of providing excellent services to clients and offers an exciting and rewarding opportunity to be at the forefront of activities related to implementing healthcare reform on a national level. The position contributes to Empower AI’s mission to deliver innovative, cost-effective solutions and services that enable customers to rapidly adapt to dynamic environments.

Requirements

Must be a Registered Nurse obtained by either a Bachelor's degree – OR - Associate's degree – OR - Diploma in Nursing.
At least four (4) years claims knowledge either from billing, reviewing, or processing of Durable Medical Equipment.
At least three (3) years clinical experience as a Registered Nurse.
Minimum two (2) years federal and local policy applications in relation to Medicare insurance procedures for medical necessity for Physician Office practices, Laboratory, and Ambulance Services.
Current licensure as a Registered Nurse in one or more of the 50 states or D.C.
Ability to keep sensitive and confidential material private.
Must have no adverse actions pending or taken against him/her by any State or Federal licensing board or program and must have no conflict of interest (COI).

Nice To Haves

Physician Office, Hospital, Suppler, or Clinic providing DME equipment care/services
Prior work as a Medicare Contractor Medical Review Nurse or Commercial Insurance for DME
Bilingual (Spanish) - Fluency in reading and understanding Spanish language especially as it relates to medical records is a plus!

Responsibilities

Perform comprehensive medical record and claims review to make payment determinations based on Insurance coverage, coding, and utilization of services and practice guidelines for Medicare DME.
Performs first and second level of Medical Review in determination of claims payment review.
Conducts in-depth claims analysis utilizing ICD-10-CM, CPT-4, and HCPCS Level II coding principles.
Utilize electronic health information imaging and input medical review decisions by electronic database module.
Utilize internet and intranet sources for policy verification.
Utilize Microsoft Office suite and other software templates as associated source input for claims review.
Make clinical judgment decisions based on clinical experience when applicable.
Responsible for review of Medicare DME claims.
Meeting quality and production standards.
Ensuring departmental compliance with quality managements system and ISO requirements.
Completes other projects or duties as assigned by the Medical Review Lead Specialist.