Medical Reviewer III – Medicare/DRG

📋 Description

• Conduct comprehensive medical record and claims reviews for Medicare to determine payment for Diagnosis Related Group (DRG) claims.

• Execute assigned projects or responsibilities as a Medical Review Specialist.

• Perform detailed claims analysis using ICD-10-CM, CPT-4, and HCPCS Level II coding principles.

• Leverage electronic health information imaging to input medical review decisions through an electronic database module.

• Access internet and intranet resources for policy verification.

• Utilize Microsoft Office suite and other software templates for claims review-related source input.

• Make clinical judgment decisions based on relevant clinical experience when necessary.

• Oversee the review of Medicare DRG claims.

• Achieve quality and production standards.

• Ensure departmental adherence to quality management systems and ISO standards.

⛳️ Requirements

• Must possess a Registered Nurse license obtained through either a Bachelor’s degree – OR - Associate's degree – OR - Diploma in Nursing.

• A minimum of four (4) years of claims experience, including billing, review, or processing of Durable Medical Equipment.

• At least three (3) years of clinical experience as a Registered Nurse.

• A minimum of two (2) years of experience applying federal and local policies related to Medicare insurance procedures for medical necessity in Physician Office practices, Laboratories, and Ambulance Services.

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

• Ability to maintain the confidentiality of sensitive materials.

• Must have no pending or imposed adverse actions from any State or Federal licensing board or program and must not have any conflict of interest (COI).

🏝️ Benefits

• Health insurance

• Professional development opportunities

• 401(k) matching plans