Medical Review Specialist V

Job not on LinkedIn

August 26

⚔️ Virginia – Remote

Although this job is listed in Virginia, this company may be open to hiring remote in other states.

⏱ Part Time

🟠 Senior

🔴 Lead

🔍🏥 Medical Reviewer

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Empower AI

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Empower AI helps federal agency leaders elevate their workforce productivity. We leverage deep technical expertise and decades of experience solving complex challenges in Civilian and Defense missions to ensure America’s missions are met. Our solutions give government leaders a direct path to meaningful transformation, equipping them with the insights and tools necessary to make critical decisions faster and move their missions forward.

501 - 1000 employees

Founded 1989

📋 Description

• Review and analyze Medicare claims sampled by the Department of Justice to make payment determinations based on coverage, coding and utilization of services and practice guidelines • Conduct medical record claims review to determine correct coding using ICD-9-CM, ICD-10, CPT-4, and HCPCS Level II • Review medical documentation for medical necessity using CMS policies, state and board regulations • Conduct in-depth claims analysis of suspected over-utilizers and analyze Standard Claims Processing files for potential fraudulent or abusive billing practices • Complete summary reports summarizing claim determinations and clinical observations for DOJ • Review and complete required number of claims reviews per pre-established production standards • Produce and submit required reports according to established content and timeframes • Communicate internally across the group and participate in QA and IRR monitoring as requested • Comply with departmental, Medicare, DOJ, and CMS policies, confidentiality, and chain-of-custody requirements • Perform in-depth research and investigation using the Internet and data analysis tools • Attend departmental and required education and training programs

🎯 Requirements

• Registered Nurse (RN) (Bachelors, Associate’s degree or diploma-based) • Current licensure as a Registered Nurse in one or more of the 50 states or D.C. • Excellent oral and written communication skills • Organization and time management skills • Knowledge of and ability to use Microsoft Excel and Word, Adobe PDFs and various internet applications • At least 10 years of clinical experience • Minimum seven (7) years claims knowledge either from billing, reviewing, or processing • 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) as defined in Section 1154(b)(1) of the Social Security Act • Medical review experience required • Previous fraud review/ investigation experience preferred • Ability to keep sensitive and confidential material private • Physical Requirements: Sitting for long periods

🏖️ Benefits

• Empower AI is proud to be recognized as a 2024 Military Friendly Employer by Viqtory.