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Medical Reviewer V
Empower AITechnical Lead Medical Review Specialist providing operational support and managing claims determinations. Critical role in implementing healthcare reform at the national level.
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
ATS Keywords
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Hard Skills & Tools
Claims ReviewPayment DeterminationsUtilization ReviewMedical Necessity AssessmentCoding Principles
Soft Skills
ConfidentialityTraining and Development
Certifications
Registered Nurse Licensure