Genetic Counselor, Clinical Reviewer
The Cigna Group
Medical Reviewer III, Medicaid
Empower AI
full-time
Posted on:
Location: 🇺🇸 United States
Visit company websiteJob Level
Mid-LevelSenior
About the role
- Conducts medical record audits to determine medical necessity and/or appropriateness of medical treatment per SOW and CMS directives
- Conducts in-depth claims analysis utilizing knowledge of medical terminology, ICD-9-CM, ICD-10-CM, CPT-4, APR-DRG, and HCPCS Level II
- Utilizes payer guidelines for coverage determinations and clinical review judgment
- Provides electronic documentation of findings and conclusions with determinations of claims payment appropriateness
- Reviews the Master Policy List and MR questionnaire for each State prior to claim review
- Ensures MR department compliance with quality management system and ISO requirements
- Utilizes electronic documentation and spreadsheets to track productivity and claim determination trends
- Participates in QA and IRR monitoring as requested
- Complies with departmental policies 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 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
- Preferred: Active professional coding certification or 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
- Physical: Sitting for long periods
