Lead Medical Review Specialist, Medicare

This is a fully remote position, open to applicants in United States.

📋 Description

• Provide operational assistance to the Medical Review Manager and the Medical Review Staff in overseeing production related to claims determinations and reviews.

• Act as a vital part in achieving our mission of delivering exceptional services to our clients.

• Ensure a stimulating and fulfilling opportunity to lead initiatives concerning the implementation of healthcare reform on a national scale.

• Review and assess sampled Medicare claims using relevant medical records to make payment decisions based on coverage, coding, and service utilization.

• Determine medical necessity using clinical review judgment in line with the CERT Program policies and contractual obligations.

• Serve as a resource for medical review specialists addressing issues related to coverage, coding, and medical necessity.

• Perform comprehensive claims analysis utilizing ICD-9-CM, ICD-10-CM, CPT-4, and HCPCS Level II coding guidelines.

• Conduct audits of medical records to evaluate the medical necessity and/or appropriateness of medical treatments based on CMS and other national standards.

⛳️ Requirements

• Bachelor’s degree – OR – Associate’s degree – OR – Diploma in Nursing.

• A minimum of three (3) years of claims experience, whether in billing, reviewing, or processing.

• At least three (3) years of clinical experience as a Registered Nurse.

• A minimum of ten (10) years of experience with federal and local policy applications related to insurance procedures for medical necessity for skilled nursing facilities and Part A claim reimbursements.

• Current licensure as a Registered Nurse in one or more of the 50 states or D.C.

• Ability to maintain the privacy of sensitive and confidential information.

• Must not have any pending or completed adverse actions against him/her by any State or Federal licensing board or program and must have no conflict of interest (COI).

🏝️ Benefits

• Empower AI is recognized as a 2024 Military Friendly Employer.

• Equal Opportunity Employer.