Medical Reviewer V

Empower AI

Technical Lead Medical Review Specialist providing operational support and managing claims determinations. Critical role in implementing healthcare reform at the national level.

Posted 7/9/2026full-timeRemote • 🇺🇸 United StatesMid-LevelSeniorWebsite

Core Competencies

Role fit

Core Competencies

Use this summary to align your resume positioning with the role.

Demonstrates expertise in claims analysis and medical review processes, utilizing ICD-9-CM, ICD-10-CM, CPT-4, and HCPCS Level II coding principles. Possesses strong clinical experience as a Registered Nurse, ensuring compliance with federal and local policies regarding medical necessity and insurance procedures.

Highest-signal resume keywords

Claims AnalysisICD-9-CM CodingICD-10-CM CodingRegistered Nurse LicensureMedical Record Audits

ATS Keywords

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Applicant Tracking System Keywords

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Hard Skills

Claims ReviewPayment DeterminationsUtilization ReviewMedical Necessity AssessmentCoding Principles

Soft Skills

ConfidentialityTraining and Development

Certifications & Qualifications

Registered Nurse Licensure

Industry Keywords

Medicare ClaimsCMS GuidelinesSkilled Nursing FacilityPart A Claim ReimbursementsFederal and Local Policy Applications

About the role

Key responsibilities & impact

Provide operational support to the Medical Review Manager and the Medical Review Staff in managing production related to claims determinations and review
Serve as a critical component in meeting our mission of providing excellent services to our clients
Review and analyze sampled Medicare claims using associated medical records
Make payment determinations based on coverage, coding, utilization of services and practice guidelines
Perform third-level Medical Review in determination of claims payment review
Conduct in-depth claims analysis utilizing ICD-9-CM, ICD-10-CM, CPT-4, and HCPCS Level II coding principles
Conducts medical record audits to determine the medical necessity and/or appropriateness of medical treatment using CMS and other national guidelines
Assist with training to integral staff for special studies as well as regular project claims review

Requirements

What you’ll need

Bachelor's degree – OR - Associate's degree – OR - Diploma in Nursing
At least three (3) years claims knowledge either from billing, reviewing, or processing
At least three (3) years clinical experience as a Registered Nurse
Minimum ten (10) years federal and local policy applications in relation to insurance procedures for medical necessity for skilled nursing facility and Part A claim reimbursements
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

Empower AI is proud to be recognized as a 2024 Military Friendly Employer by Viqtory
Company offers support for active-duty and veteran employees