Medical Review Specialist – Senior

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

📋 Description

• Assess and evaluate Medicare claims selected by the Department of Justice to determine payment outcomes.

• Examine medical records for accurate coding in accordance with ICD-9-CM, ICD-10, CPT-4, and HCPCS Level II standards.

• Scrutinize medical documentation to ensure medical necessity based on CMS policies, guidelines, and relevant state and board regulations.

• Investigate suspected over-utilizers and Standard Claims Processing files to identify potentially fraudulent or abusive billing behaviors.

• Prepare summary reports detailing claim assessments, clinical findings, and any additional requested information.

• Fulfill the mandated number of claims reviews in line with project production benchmarks.

• Generate and submit necessary reports within specified content and timing requirements.

• Collaborate internally with all levels of the team.

• Engage in Quality Assurance and IRR monitoring as needed.

• Adhere to departmental, Medicare, DOJ, and CMS policies, regulations, and directives.

• Participate in departmental educational and training activities.

• Conduct research and investigations utilizing the Internet and data analysis tools.

• Maintain the chain of custody for documents while following confidentiality and security protocols.

• Complete tasks that meet or surpass contract quality assurance standards.

⛳️ Requirements

• Registered Nurse (RN) with a bachelor’s degree, associate’s degree, or diploma-based qualification.

• Current licensure as a Registered Nurse in one or more of the 50 states or D.C.

• A minimum of 10 years of clinical experience.

• At least 7 years of experience in claims, including billing, reviewing, or processing.

• Required experience in medical review.

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

• No conflicts of interest as outlined in Section 1154(b)(1) of the Social Security Act.

• Strong oral and written communication abilities.

• Effective organizational and time management skills.

• Proficiency in Microsoft Excel and Word, Adobe PDFs, and various internet applications.

• Capability to maintain the privacy of sensitive and confidential information.

• Ability to sit for extended periods.

• Previous experience in fraud review/investigation is preferred.

🏝️ Benefits

• Recognition as a Military Friendly Employer with support for active-duty and veteran employees.

• Comprehensive total compensation package.

• Access to required education and training programs.