Job Description:
• Perform comprehensive medical record and claims review to make payment determinations based on Insurance coverage, coding, and utilization of services and practice guidelines for Medicare A, Outpatient Facilities and Services.
• Performs first and second level of Medical Review in determination of claims payment review
• Conducts in-depth claims analysis utilizing ICD-10-CM, CPT-4, and HCPCS Level II coding principles
• Utilize electronic health information imaging and input medical review decisions by electronic database module.
• Utilize internet and intranet sources for policy verification.
• Utilize Microsoft Office suite and other software templates as associated source input for claims review.
• Make clinical judgment decisions based on clinical experience when applicable.
• Responsible for review of Medicare Part A claims.
• Meeting quality and production standards.
• Ensuring departmental compliance with quality managements system and ISO requirements.
• Completes other projects or duties as assigned by the Lead Medical Review Specialist
Requirements:
• Must be a Registered Nurse obtained by either a Bachelor's degree – OR - Associate's degree – OR - Diploma in Nursing.
• At least four (4) years related experience.
• At least three (3) years clinical experience as a Registered Nurse.
• 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).
• Preferred Education and Experience: Medicare Part A RN clinical review
• Minimum two (2) years federal and local policy applications in relation to Medicare insurance procedures for medical necessity for Outpatient Facilities and Services.
• Prior work as a Medicare Contractor Medical Review Nurse or Commercial Insurance Home Health RN review experience.
• Optional - Bilingual (Spanish) - Fluency in reading and understanding Spanish language especially as it relates to medical records is a plus!
Benefits:
• Empower AI is proud to be recognized as a 2024 Military Friendly Employer by Viqtory, the publisher of G.I. Jobs.
• Flexible work arrangements