Medical Reviewer III, Medicaid
Empower AI
Medical Reviewer III, Medicaid
Empower AI
full-time
Posted on:
Origin: • 🇺🇸 United States
Visit company websiteJob Level
Mid-LevelSenior
About the role
- Conducts medical record audits to determine the medical necessity and/or appropriateness of medical treatment as defined by the Statement of Work and CMS directives as well as state and local specific regulations
- Conducts in-depth claims analysis utilizing extensive knowledge of medical terminology, ICD-9-CM, ICD-10-CM, CPT-4, APR-DRG, and HCPCS Level II coding principles
- Utilizes payer guidelines for coverage determinations
- Makes determination of the claim’s medical appropriateness utilizing clinical review judgment in accordance with PERM policies and contract responsibilities
- Provides electronic documentation of findings and conclusions with determinations of claims payment appropriateness
- Reviews the Master Policy List and the MR questionnaire for each State prior to the review of claims for that State
- Ensures the MR department’s compliance with quality management system and ISO requirements
- Utilizes electronic documentation and spreadsheets to track personal productivity and claim determination trends
- Participates in QA and IRR monitoring as requested
- Complies with departmental policies and procedures and QA/productivity benchmarks
- Attends departmental or required education and training programs
- Effectively communicates with management and colleagues
- Performs other projects or duties as assigned by the Senior Medical Review Specialist or Medical Review Manager
Requirements
- Active RN state licensure
- 4-9 years experience
- At least four (4) years clinical experience in a medical/surgical setting
- At least two (2) years of medical record audit experience
- Familiarity with Medicaid and/or CHIP program
- Critical thinking and analytical skills
- Highly developed organization and time management skills
- Ability to work in a telecommute team environment
- 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
- Active professional coding certification or the ability to obtain certification within eighteen (18) months of employment (preferred)
- Demonstrated knowledge of ICD-9-CM, ICD-10-CM, CPT-4, APR-DRG, and HCPCS Level II coding principles (preferred)
- Familiarity with CERT, DOJ, ZPIC, UPIC, or PERM claim audits (preferred)
- Sitting for long periods (physical requirement)
