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Medical Reviewer III – Medicare/DRG
Empower AIMedical Reviewer III responsible for comprehensive review of Medicare DRG claims with Empower AI. Ensuring payment determinations based on clinical judgment and policy compliance.
About the role
Key responsibilities & impact- Perform Medicare comprehensive medical record and claims review to make payment determinations for Diagnosis Related Group (DRG) claims.
- Perform projects or duties as assigned as a Medical Review Specialist.
- Conduct 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 DRG claims.
- Meeting quality and production standards.
- Ensuring departmental compliance with quality managements system and ISO requirements.
Requirements
What you’ll need- 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 (3) 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
Comp & perks- Health insurance
- Professional development opportunities
- 401(k) matching plans
ATS Keywords
✓ Tailor your resumeApplicant Tracking System Keywords
Tip: use these terms in your resume and cover letter to boost ATS matches.
Hard Skills & Tools
ICD-10-CMCPT-4HCPCS Level IIclaims analysisclinical judgmentMedicare claims reviewquality management systemISO requirementsDurable Medical Equipment billingmedical necessity
Soft Skills
clinical experienceconfidentialitydecision makingattention to detailquality standards
Certifications
Registered NurseBachelor's degree in NursingAssociate's degree in NursingDiploma in Nursing