Medical Review Specialist, Senior

🕒 January 22

⚔️ Virginia – Remote

⚔️ Virginia – Remote

💵 $36 - $57 / hour

⏱ Part Time

🟠 Senior

🔴 Lead

🔍🏥 Medical Reviewer

👻 Ghost score 45%

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 using associated medical records • Make payment determinations based on coverage, coding, 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 coding principles • Review medical documentation for medical necessity using clinical knowledge, CMS policies and guidelines, and state and board regulations • Conduct in-depth claims analysis of suspected over-utilizers and suspected fraudulent billing practices • Analyze Standard Claims Processing files to detect potential fraudulent or abusive billing practices or vulnerabilities in Medicare and/or Medicaid payment policies • Complete summary reports of claim determinations, clinical observations and requested information • Complete the required number of claims reviews according to production standards • Produce and submit required reports according to established content and timeframes • Communicate internally with all levels of the group • Participate in Quality Assurance and IRR monitoring as requested • Comply with departmental policies and procedures, Medicare and DOJ guidelines, and CMS directives • Attend departmental and required education and training programs • Review Standard Claims Processing System information to determine provider billing patterns and detect potentially fraudulent or abusive practices • Utilize Medicare/Medicaid guidelines for coverage determinations • Perform in-depth research and investigation using the Internet and other tools, including data analysis tools • Maintain chain of custody on documents and follow confidentiality and security guidelines • Complete assignments meeting or exceeding contract quality assurance goals

🎯 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 • Must have no conflict of interest (COI) as defined in Section 1154(b)(1) of the Social Security Act • Medical review experience required • Ability to keep sensitive and confidential material private • Ability to sit for long periods

🏖️ Benefits

• Casual/part-time position • Departmental and required education and training programs