Medical Reviewer III, Medicare/DME
Empower AI
full-time
Posted on:
Location Type: Remote
Location: Remote • 🇺🇸 United States
Visit company websiteJob Level
Mid-LevelSenior
About the role
- Perform comprehensive medical record and claims review to make payment determinations based on Insurance coverage, coding, and utilization of services and practice guidelines for Medicare DME.
- Performs first and second level of Medical Review in determination of claims payment review.
- Conducts in-depth claims analysis utilizing ICD-10-CM, CPT-4, and HCPCS Level II coding principles.
- Utilize electronic health information imaging and input medical review decisions by electronic database module.
- Utilize internet and intranet sources for policy verification.
- Utilize Microsoft Office suite and other software templates as associated source input for claims review.
- Make clinical judgment decisions based on clinical experience when applicable.
- Responsible for review of Medicare DME claims.
- Meeting quality and production standards.
- Ensuring departmental compliance with quality managements system and ISO requirements.
- Completes other projects or duties as assigned by the Medical Review Lead Specialist.
Requirements
- Must be a Registered Nurse obtained by either a Bachelor's degree – OR - Associate's degree – OR - Diploma in Nursing.
- At least four (4) years claims knowledge either from billing, reviewing, or processing of Durable Medical Equipment.
- At least three (4) years clinical experience as a Registered Nurse.
- Minimum two (2) years federal and local policy applications in relation to Medicare insurance procedures for medical necessity for Physician Office practices, Laboratory, and Ambulance Services.
- 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).
Benefits
- Flexible working arrangements
- Professional development opportunities
Applicant Tracking System Keywords
Tip: use these terms in your resume and cover letter to boost ATS matches.
Hard skills
ICD-10-CM codingCPT-4 codingHCPCS Level II codingclaims analysismedical record reviewpayment determinationclinical judgmentutilization reviewquality managementISO compliance
Soft skills
clinical experienceconfidentialitydecision makingattention to detailorganizational skillscommunication skillsproblem solvingtime managementteam collaborationadaptability
Certifications
Registered Nurse licensureBachelor's degree in NursingAssociate's degree in NursingDiploma in Nursing