Medical Review Analyst

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

📋 Description

• Perform thorough reviews of medical records and utilize sound clinical judgment to determine claim payment outcomes.

• Investigate medical claims data and other relevant information to identify any issues.

• Analyze complex data model outputs.

• Utilize tools to identify potential fraudulent activities and assist in fraud investigations and information requests.

• Identify and build cases for future administrative actions, including referrals to law enforcement, educational initiatives, and recovery of overpayments.

• Collaborate with external agencies to develop cases and implement corrective measures.

• Address requests for data and provide necessary support.

• Highlight issues of concern, referencing regulatory breaches and suspected schemes aimed at defrauding the Government.

• Investigate regulations and document any violations.

• Conduct independent research to identify issues related to Medicaid payments for both institutional and non-institutional providers.

• Make payment decisions on claims based on clinical expertise.

• May be required to testify in court regarding findings from investigations.

• Draft correspondence, reports, and summary letters for referrals.

• Maintain effective communication both internally and externally.

• Manage confidential information responsibly.

• Report work activities promptly.

• Work autonomously as well as collaboratively within a team.

• Participate in meetings, training sessions, and conferences; overnight travel may be necessary.

⛳️ Requirements

• Minimum of 5 years of experience with a Bachelor's degree.

• Background in the medical field as a Registered Nurse or another clinician, and/or experience in reviewing medical claims for coverage and medical necessity.

• Must hold a current nursing license.

• Possess strong investigative skills.

• Excellent communication and organizational abilities.

• Capability to apply Federal, State, and Managed Care Organization (MCO) regulations to claims being reviewed.

• Proficient computer knowledge and skills.

• U.S. citizenship is required.

• Experience in reviewing claims for technical compliance, conducting medical reviews, and/or developing fraud cases.

• Familiarity with cases involving Medicaid services.

• Certification as a CPC (Certified Professional Coder) is preferred.

🏝️ Benefits

• Comprehensive medical, dental, and vision insurance.

• Life insurance coverage.

• Health savings account options.

• Short-term and long-term disability benefits.

• Employee assistance program (EAP).

• Parental leave provided.

• 401(k) retirement plan.

• Paid time off (PTO) for vacations.

• Company-paid holidays.

• Eligibility for overtime.

• Shift differential eligibility.

• Qualification for discretionary bonuses.