Medical Reviewer V

Empower AI Inc. • Remote,

3d

About The Position

Empower AI is looking for a Technical Lead Medical Review Specialist (Medical Reviewer V) to provide operational support to the Medical Review Manager and the Medical Review Staff in managing production related to claims determinations and review. This role is a critical component in meeting the mission of providing excellent services to clients and offers an exciting opportunity to be at the forefront of activities related to implementing healthcare reform on a national level. The position contributes to Empower AI, Inc.'s mission to deliver innovative, cost-effective solutions and services that enable customers to rapidly adapt to dynamic environments.

Requirements

• Bachelor's degree – OR - Associate's degree – OR - Diploma in Nursing.
• At least three (3) years claims knowledge either from billing, reviewing, or processing.
• At least three (3) years clinical experience as a Registered Nurse.
• Minimum ten (10) years federal and local policy applications in relation to insurance procedures for medical necessity for skilled nursing facility and Part A claim reimbursements.
• 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

• Skilled nursing claims review experience and Part A claim reimbursements
• Prior work as a Medicare Contractor Medical Review Nurse
• Bilingual (Spanish) - Fluency in reading and understanding Spanish language especially as it relates to medical records is a plus!

Responsibilities

• Reviews and analyzes sampled Medicare claims using associated medical records, to make payment determinations based on coverage, coding, utilization of services and practice guidelines
• Makes medical necessity determinations utilizing clinical review judgment in accordance with the CERT Program policies and contract responsibilities
• Serves as a resource for medical review specialists involving coverage, coding, and medical necessity issues
• Performs third level of Medical Review in determination of claims payment review when the first and second level medical review determinations are in opposition
• Can perform first or second level medical review as needed
• Conducts in-depth claims analysis utilizing ICD-9-CM, ICD-10-CM, CPT-4, and HCPCS Level II coding principles
• Applies the interpretation of ANSI Reason Codes, Revenue Codes, timely MAC Edits and Audit codes and other Medicare billing formats in determination of appropriate billing submissions and reimbursement
• Conducts medical record audits to determine the medical necessity and/or appropriateness of medical treatment using CMS and other national guidelines, as well as local medical review policies
• Provides research and updates to specialty claims review and review team needs
• Provides electronic documentation of findings and conclusions with determinations of claims payment appropriateness in review tool fields
• Reviews and completes referred level claim reviews in accordance to production standards for special studies as well as regular project claims for end of reporting requirements
• Assists with training to integral staff for special studies as well as regular project claims review
• Assists as needed for QC Panel reviews
• Prepares review for IRR Panel as needed
• Attends Medical Review Lead meetings when necessary and invited
• Assists with questions from medical records or customer service with regard to specific claim type experience
• Complies with Program Integrity Manual (PIM) and Statement of Work (SOW) guidelines and CMS directives and regulations pertaining to integrity, fraud, overpayments, and the handling and disclosure of information
• Complies with departmental policies and procedures.
• Communicates internally with all levels of the CERT Program
• Attends departmental or required education and training programs
• Completes other projects or duties as assigned by the Medical Review Manager

What This Job Offers

• Job Type: Full-time
• Career Level: Senior
• Education Level: Associate degree