Medical Review Analyst – Medicare

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

📋 Description

• Perform reviews of medical records and utilize sound clinical judgment to make decisions regarding claim payments.

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

• Analyze complex data model outputs and employ tools to uncover potential fraud.

• Assist in ongoing fraud investigations and fulfill information requests.

• Identify and formulate cases for administrative actions, which may include law enforcement referrals, educational initiatives, and recovery of overpayments.

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

• Address data requests and provide support as needed.

• Raise concerns by citing regulatory violations and alleging schemes or fraudulent activities against the Government.

• Investigate regulations and document any violations found.

• Conduct independent research on Medicare payments to both institutional and non-institutional providers.

• Draft correspondence, reports, and summaries for referrals.

• Effectively communicate with both internal and external stakeholders.

• Manage confidential information responsibly.

• Timely report work activities.

• Work autonomously as well as collaboratively within a team.

• Participate in meetings, training sessions, and conferences as required.

• May need to testify in court regarding findings from work.

• Overnight travel may be necessary.

⛳️ Requirements

• A Bachelor's degree with 5 years of experience, a Master's degree with 3 years of experience, or an Associate's degree with 7 years of experience.

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

• A current/active Nursing or Physical Therapy license in the state of residence.

• Excellent investigative abilities.

• Strong communication and organizational skills.

• Proficient knowledge and skills in PC usage.

• U.S. citizenship is required.

• Experience in evaluating claims for technical compliance, conducting medical reviews, and/or building fraud cases is desirable.

• Familiarity with Medicare requirements, laws, rules, and regulations regarding payment for billed services is desirable.

• CPC (Certified Professional Coder) certification is desirable.

🏝️ Benefits

• Telework options available within the contiguous United States.

• Overnight travel may be necessary.

• Employees may qualify for overtime pay, shift differentials, and a discretionary bonus in addition to their base salary.