Medical Review Specialist – Senior

🔥 15 hours ago

⚔️ Virginia – Remote

⚔️ Virginia – Remote

💵 $36 - $57 / hour

⏱ Part Time

🟠 Senior

🔴 Lead

🔍🏥 Medical Reviewer

👻 Ghost score 1%

What it means: how likely this posting is sitting open without active hiring.How to read it: 60% or higher means we think this is a ghost. Lower scores are less of a worry.How we score it: age, reposts, open roles vs team size, how fast jobs close, and whether pay is listed.Fine print: an estimate from public data, not a judgment of the company. Real jobs can score high, so treat it as a hint, not a fact.

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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

• Review and analyze Medicare claims sampled by the Department of Justice to make payment determinations • Review medical records for correct coding using ICD-9-CM, ICD-10, CPT-4, and HCPCS Level II principles • Review medical documentation for medical necessity using CMS policies, guidelines, and applicable state and board regulations • Analyze suspected over-utilizers and Standard Claims Processing files to detect potentially fraudulent or abusive billing practices • Complete summary reports describing claim determinations, clinical observations, and other requested information • Complete the required number of claims reviews according to project production standards • Produce and submit required reports within established content and timeframes • Communicate internally with all levels of the group • Participate in Quality Assurance and IRR monitoring as requested • Comply with departmental, Medicare, DOJ, and CMS policies, regulations, and directives • Attend departmental education and training programs • Research and investigate using the Internet and data analysis tools • Maintain chain of custody for documents and follow confidentiality and security guidelines • Complete assignments meeting or exceeding contract quality assurance goals

🎯 Requirements

• Registered Nurse (RN) with a bachelor’s degree, associate’s degree, or diploma-based qualification • Current licensure as a Registered Nurse in one or more of the 50 states or D.C. • At least 10 years of clinical experience • Minimum 7 years of claims knowledge from billing, reviewing, or processing • Medical review experience required • No adverse actions pending or taken against the candidate by any State or Federal licensing board or program • No conflict of interest as defined in Section 1154(b)(1) of the Social Security Act • Excellent oral and written communication skills • Organization and time management skills • Knowledge of Microsoft Excel and Word, Adobe PDFs, and various internet applications • Ability to keep sensitive and confidential material private • Ability to sit for long periods • Previous fraud review/investigation experience preferred

🏖️ Benefits

• Military Friendly Employer recognition and support for active-duty and veteran employees • Total compensation package • Required education and training programs