Medical Reviewer III
Empower AI
contract
Posted on:
Location Type: Remote
Location: United States
Visit company websiteExplore more
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 A, Outpatient Facilities and Services.
- 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 Part A 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 Lead Medical Review 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 related experience.
- At least three (3) years clinical experience as a Registered Nurse.
- 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).
- Preferred Education and Experience: Medicare Part A RN clinical review
- Minimum two (2) years federal and local policy applications in relation to Medicare insurance procedures for medical necessity for Outpatient Facilities and Services.
- Prior work as a Medicare Contractor Medical Review Nurse or Commercial Insurance Home Health RN review experience.
- Optional - Bilingual (Spanish) - Fluency in reading and understanding Spanish language especially as it relates to medical records is a plus!
Benefits
- Empower AI is proud to be recognized as a 2024 Military Friendly Employer by Viqtory, the publisher of G.I. Jobs.
- Flexible work arrangements
Applicant Tracking System Keywords
Tip: use these terms in your resume and cover letter to boost ATS matches.
Hard Skills & Tools
ICD-10-CM codingCPT-4 codingHCPCS Level II codingclaims analysismedical record reviewclinical judgmentMedicare Part A reviewutilization reviewquality managementISO compliance
Soft Skills
confidentialityclinical experiencedecision makingattention to detailcommunication
Certifications
Registered Nurse licensure