Lead Medical Review Specialist, Medicare

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Empower AI

WebsiteLinkedInAll Job Openings

501 - 1000 employees

Founded 1989

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.

📋 Description

• 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. • Ensure an exciting and rewarding opportunity to be at the forefront of activities related to implementing healthcare reform on a national level. • Review and analyze sampled Medicare claims using associated medical records to make payment determinations based on coverage, coding, and utilization of services. • Make medical necessity determinations utilizing clinical review judgment in accordance with the CERT Program policies and contract responsibilities. • Serve as a resource for medical review specialists involving coverage, coding, and medical necessity issues. • Conduct in-depth claims analysis utilizing ICD-9-CM, ICD-10-CM, CPT-4, and HCPCS Level II coding principles. • Conduct medical record audits to determine the medical necessity and/or appropriateness of medical treatment using CMS and other national guidelines.

🎯 Requirements

• 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

• Empower AI is a 2024 Military Friendly Employer • Equal Opportunity Employer