Medical Review Analyst – Medicare

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

📋 Description

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

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

• Analyze outputs from complex data models.

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

• Recognize and develop cases for future administrative actions, which may include referrals to law enforcement, educational initiatives, and recovery of overpayments.

• Collaborate with external agencies to formulate cases and implement corrective actions.

• Address requests for data and provide necessary support.

• Highlight issues of concern by citing regulatory violations and presenting allegations of schemes or scams aimed at defrauding the Government.

• Investigate regulations and document violations.

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

• Make claim payment determinations based on clinical expertise.

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

• Record work activities promptly.

• Participate in meetings, training sessions, and conferences.

• Testify in court regarding work findings as needed.

⛳️ Requirements

• 5 years of experience with a BS/BA; 3 years with an MS/MA; no experience required with a PhD.

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

• Current and active Nursing or Physical Therapy license.

• Exceptional investigative skills.

• Strong communication and organizational abilities.

• Proficient in PC usage and skills.

• U.S. citizenship is mandatory.

• Experience in claims review for technical requirements, conducting medical reviews, and/or developing fraud cases is preferred.

• CPC (Certified Professional Coder) certification is desirable.

• Capability to testify in court about work findings.

• Proficient in composing correspondence, reports, and referral summary letters.

• Effective internal and external communication skills.

• Ability to manage confidential information.

• Timely reporting of work activities is essential.

• Capacity to work independently as well as collaboratively within a team.

• Willingness to attend meetings, training, and conferences.

• Overnight travel is required.

🏝️ Benefits

• Medical insurance.

• Dental insurance.

• Vision insurance.

• Life insurance.

• Health savings account.

• Short-term disability.

• Long-term disability.

• Employee assistance program (EAP).

• Parental leave.

• 401(k) plan.

• Paid time off (PTO) for vacations.

• Company-paid holidays.

• Overtime eligibility.

• Shift differential eligibility.

• Eligibility for discretionary bonuses.