Medical Reviewer V

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

📋 Description

• Deliver operational assistance to the Medical Review Manager and the Medical Review Staff in overseeing production related to claims determinations and evaluations.

• Act as a vital element in achieving our goal of providing exceptional services to our clients.

• Evaluate and analyze selected Medicare claims alongside relevant medical records.

• Determine payment eligibility based on coverage, coding, service utilization, and practice guidelines.

• Perform third-level Medical Review in the assessment of claims payment reviews.

• Engage in comprehensive claims analysis utilizing ICD-9-CM, ICD-10-CM, CPT-4, and HCPCS Level II coding standards.

• Conduct medical record audits to assess the medical necessity and/or appropriateness of medical treatments using CMS and other national guidelines.

• Support training for essential staff for specialized studies as well as routine project claims evaluations.

⛳️ Requirements

• Bachelor's degree – OR - Associate's degree – OR - Diploma in Nursing.

• A minimum of three (3) years of claims knowledge from billing, reviewing, or processing.

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

• A minimum of ten (10) years applying federal and local policies concerning insurance procedures for medical necessity for skilled nursing facilities and Part A claim reimbursements.

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

• Capable of maintaining the privacy of sensitive and confidential information.

• Must have no pending or taken adverse actions against him/her by any State or Federal licensing board or program and must have no conflict of interest (COI).

🏝️ Benefits

• Empower AI is honored to be recognized as a 2024 Military Friendly Employer by Viqtory.

• The company provides support for active-duty and veteran employees.