Medical Review Specialist III – DRG Claims

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

📋 Description

• Conduct thorough reviews of Medicare medical records and claims for DRG-reimbursed inpatient acute hospital admissions.

• Make payment determinations based on coverage by insurance, coding practices, utilization of services, and established guidelines.

• Utilize electronic health information imaging and input medical review decisions into an electronic database module.

• Confirm policies using both internet and intranet resources.

• Employ Microsoft Office and software templates as inputs for claim reviews.

• Utilize clinical judgment based on clinical experience.

• Examine Medicare DRG claims.

• Oversee the analysis of provider- and service-specific claims to identify discrepancies.

• Achieve quality and production benchmarks.

• Ensure departmental adherence to the quality management system and ISO standards.

• Execute projects or tasks assigned by the Lead Medical Review Specialist.

⛳️ Requirements

• Bachelor’s degree, associate’s degree, or diploma in nursing.

• A minimum of four years of claims expertise in billing, reviewing, or processing.

• At least four years of clinical experience in medical-surgical settings as a Registered Nurse.

• Minimum of four years of experience applying federal and local policies to insurance processes for medical necessity, including the Two Midnight Rule for DRG acute inpatient hospital admissions.

• Current Registered Nurse licensure in one or more U.S. states or the District of Columbia.

• Capacity to maintain sensitive and confidential information securely.

• No pending or prior adverse actions against the candidate by any State or Federal licensing board or program.

• No existing conflict of interest.

• Valid state driver’s license for the state of residence.

• Preference for candidates with prior inpatient utilization review experience.

• Preferred knowledge of ICD-10-CM, PCS, and CPT-4 coding.

• Previous experience as a Medicare Contractor Medical Review Nurse is preferred.

• Bilingual proficiency in Spanish for reading and understanding medical records is optional/preferred.

🏝️ Benefits

• Equal opportunity and affirmative action.

• Company-sponsored training programs.

• Educational assistance opportunities.

• Social and recreational activities.

• Military-friendly employer supporting active-duty and veteran employees.