Medical Review Specialist V
Empower AI
part-time
Posted on:
Location Type: Remote
Location: Virginia • United States
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About the role
- Review and analyze Medicare claims sampled by the Department of Justice, using associated medical records, to make payment determinations based on coverage, coding and utilization of services and practice guidelines.
- Conducts medical record claims review to determine correct coding, utilizing ICD-9-CM, ICD-10, CPT-4, and HCPCS Level II coding principles.
- Review medical documentation for medical necessity utilizing clinical knowledge and CMS policies and guidelines, as well as other state and board regulations.
- Conducts in-depth claims analysis of suspected over-utilizers who are suspect of fraudulent billing practices.
- Completes summary report upon completion of the records review, summarizing claim determinations, clinical observations and other information requested by the DOJ.
- Reviews and completes the required number of claims reviews in accordance to pre-established production standards for the project.
- Produces and submits required reports according to established content and timeframes.
- Communicates internally with all levels of the group.
- Participates in Quality Assurance (QA) and IRR monitoring as requested.
- Complies with departmental policies and procedures.
- Complies with Medicare and DOJ guidelines and CMS directives, policies and regulations pertaining to integrity, fraud, overpayments, and the handling and disclosure of information.
- Attends departmental and required education and training programs.
- Reviews information contained in Standard Claims Processing System to determine provider billing patterns and detect fraudulent or abusive billing practices or vulnerabilities in Medicare payment policies.
- Utilizes the Medicare/Medicaid guidelines for coverage determinations.
- Performs in-depth research and investigation utilizing the Internet and other tools, including data analysis tools.
- Maintains chain of custody on all documents, follows all confidentiality and security guidelines.
Requirements
- Registered Nurse (RN) (Bachelors, Associate’s degree or diploma-based)
- Current licensure as a Registered Nurse in one or more of the 50 states or D.C.
- Excellent oral and written communication skills
- Organization and time management skills
- Knowledge of and ability to use Microsoft Excel and word, Adobe PDFs and various internet applications
- At least 10 years of clinical experience
- Minimum seven (7) years claims knowledge either from billing, reviewing, or processing.
- 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) as defined in Section 1154(b)(1) of the Social Security Act
- Medical review experience required
- Previous fraud review/ investigation experience preferred
- Ability to keep sensitive and confidential material private.
Benefits
- Health insurance
- Flexibility with work hours
- Professional development opportunities
Applicant Tracking System Keywords
Tip: use these terms in your resume and cover letter to boost ATS matches.
Hard Skills & Tools
ICD-9-CMICD-10CPT-4HCPCS Level IIclaims analysismedical record reviewfraud detectiondata analysisclinical knowledgeMedicare/Medicaid guidelines
Soft Skills
oral communicationwritten communicationorganizationtime managementconfidentialityattention to detailanalytical thinkinginterpersonal skillsreport writingquality assurance
Certifications
Registered Nurse (RN) licensure