Medicare Medical Review RN (Medical Reviewer III)

CoventBridge Group

10d•$65,000 - $75,000•Remote

About The Position

Medicare Medical Review RN (Medical Reviewer III) - REMOTE The Medicare Medical Review RN (Medical Reviewer III) will primarily be responsible for conducting clinical reviews of medical records during the course of fraud investigations or other program integrity initiatives such as requests for information or in support of proactive data analysis efforts. In addition, this position applies Medicare and Medicaid guidelines in making clinical determinations as to the appropriateness of payment coverage. In assuming this position, you will be a critical contributor to meeting CoventBridge Group's objective: To provide services to our clients that exceed their expectations and contribute to improved healthcare delivery by identifying and eliminating fraud, waste and abuse. This position will report directly to the Medical Review Supervisor and will work in our Grove City, OH office. If not local, remotely from a home office.

Requirements

2 years minimum experience at a government contractor (ZPIC, UPIC, RAC, MAC, etc.)
2 years minimum working knowledge of ICS 10-CM/CPT coding experience
4 years minimum experience of working knowledge of Diagnosis Related Groups (DRG's), Prospective Payment Systems or Part B claims and Medicare coverage guidelines
Knowledge of, and the ability to correctly identify, Medicare and Medicaid coverage guidelines
Advance knowledge of medical terminology and experience in the analysis and processing of Medicare claims, utilization review/ quality assurance procedures, ICD 10-CM and CPT coding, Medicare coverage guidelines and payment methodologies (i.e., Correct Coding Initiative, DRG's, Prospective Payment Systems and Ambulatory Surgical center), NCPCP and other types of prescription drug claims
Ability to read Medicare claims, both paper and electronic, and a basic knowledge of the Medicare claims systems is required
Should possess excellent oral and written communication skills with an ability to write professional summary reports
Knowledge of and ability to use Microsoft Word, Excel, and Internet applications
Able to efficiently organize and manage workload and assignments
Must have and maintain a valid driver' license for the associate's state of residence as onsite audits are part of the role as a nurse reviewer
Graduate from an accredited school of nursing and have an active license as a Registered Nurse (RN) required

Nice To Haves

Preference given to BSN or higher prepared nurses with recent medical review claims experience in Medicare or Medicaid reviews

Responsibilities

Reviews information contained in Standard Claims Processing System files (e.g., claims history, provider files) to determine provider billing patterns and to detect potentially fraudulent or abusive billing practices or vulnerabilities in Medicare or Medicaid payment policies
Utilizes extensive knowledge of medical terminology, ICD-9-CM, ICD-10-CM HCPCS Level II and CPT coding along with analysis and processing of Medicare claims. Utilizes Medicare/Medicaid and Contractor guidelines for coverage determinations
Coordinates and compiles the written Investigative Summary Report to the PI Investigator upon completion of the records review
Incorporates leadership and communication skills to work with physicians and other health professionals as well as external regulatory agencies and law enforcement personnel
Provides training to UPIC staff on medical terminology, reading medical records, and policy interpretation
Provides expert witness testimony as required
Completes assignments in a manner that meets or exceeds the quality assurance goal of 98% accuracy
Maintains chain of custody on all documents and follows all confidentiality and security guidelines
Performs other duties as assigned by the Medical Review Supervisor that contribute to UPIC goals and objectives and comply with the Program Integrity Manual and Statement of Work guidelines and CMS directives and regulations