Medical Review Specialist III – DRG Claims

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Empower AI

WebsiteLinkedInAll Job Openings

501 - 1000 employees

Founded 1989

🎖️ Defense

🏥 Healthcare

📦 Logistics

Defense • Healthcare • Logistics

Empower AI, formerly known as NCI, is a company that enhances the capabilities of public sector teams through advanced artificial intelligence solutions. With a focus on federal agencies, Empower AI leverages its extensive technical expertise to address complex challenges in both Civilian and Defense missions, enabling government leaders to boost workforce productivity and make informed decisions quickly. The company's offerings encompass a range of specialties, including AI, cybersecurity, software development, and cloud migration, aimed at facilitating meaningful transformation within government operations.

📋 Description

• Perform comprehensive Medicare medical record and claims reviews for DRG-reimbursed inpatient acute hospital admissions • Make payment determinations based on insurance coverage, coding, utilization of services, and practice guidelines • Use electronic health information imaging and enter medical review decisions into an electronic database module • Verify policies using internet and intranet sources • Use Microsoft Office and software templates as claim-review inputs • Make clinical judgment decisions based on clinical experience • Review Medicare DRG claims • Supervise analysis of provider- and service-specific claims to identify errors • Meet quality and production standards • Ensure departmental compliance with the quality management system and ISO requirements • Perform projects or duties assigned by the Lead Medical Review Specialist

🎯 Requirements

• Bachelor's degree, associate's degree, or diploma in nursing • At least four years of claims knowledge from billing, reviewing, or processing • At least four years of medical-surgical clinical experience as a Registered Nurse • Minimum four years applying federal and local policies to insurance procedures for medical necessity, including the Two Midnight Rule in DRG acute inpatient hospital admissions • Current Registered Nurse licensure in one or more U.S. states or the District of Columbia • Ability to keep sensitive and confidential material private • No adverse actions pending or taken against the candidate by any State or Federal licensing board or program • No conflict of interest • Valid state driver's license for the state of residence • Prior inpatient utilization review experience preferred • ICD-10-CM, PCS, and CPT-4 coding knowledge preferred • Prior work as a Medicare Contractor Medical Review Nurse preferred • Bilingual Spanish fluency in reading and understanding medical records is optional/preferred

🏖️ Benefits

• Equal opportunity and affirmative action • Company-sponsored training • Educational assistance • Social and recreational programs • Military-friendly employer supporting active-duty and veteran employees