Medical Review Analyst – Medicare

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

📋 Description

• Perform reviews of medical records while applying sound clinical judgment to decisions regarding claim payments.

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

• Analyze complex data model outputs and utilize tools to uncover potential fraudulent activities.

• Assist with ongoing fraud investigations and fulfill information requests.

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

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

• Address requests for data and provide necessary support.

• Raise concerns by presenting issues that cite regulatory violations and allege schemes intended to defraud the Government.

• Investigate regulations and document violations.

• Undertake independent research into Medicare payments for both institutional and non-institutional providers.

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

• Communicate effectively with both internal and external stakeholders.

• Manage confidential information appropriately.

• Timely report work activities.

• Attend meetings, training sessions, and conferences as required.

• May be required to appear in court to provide testimony regarding findings from work.

⛳️ Requirements

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

• Minimum of 3 years of experience in the medical field as a Registered Nurse or another clinician, and/or experience reviewing medical claims for coverage and medical necessity.

• Current/Active Nursing or Physical Therapy license in the state of residence.

• Demonstrated strong investigative skills.

• Excellent communication and organizational abilities.

• Proficient computer skills and knowledge.

• U.S. citizenship is required.

• Experience in assessing claims for technical requirements, conducting medical reviews, and/or creating fraud cases.

• Familiarity with Medicare requirements, laws, rules, and regulations concerning service billing.

• CPC (Certified Professional Coder) certification is preferred.

🏝️ Benefits

• Telework options available from within the contiguous United States.

• Overnight travel may be necessary.

• Employees may qualify for overtime, shift differentials, and discretionary bonuses in addition to base salary.

• Commitment to equal opportunity employment, including for individuals with disabilities and protected veterans, as well as other characteristics safeguarded by law.