Medical Reviewer V

By | September 12, 2022

Job Responsibilities : Medical Reviewer V

Salary : $104000 per year

Company : Empower AI Inc.

Location : Remote US

Educational requirements : Graduate

Overview:

Empower AI is AI for government. Empower AI gives federal agency leaders the tools to elevate the potential of their workforce with a direct path for meaningful transformation. Headquartered in Reston Va. Empower AI leverages three decades of experience solving complex challenges in Health Defense and Civilian missions. Our proven Empower AI Platform® provides a practical sustainable path for clients to achieve transformation that is true to who they are what they do how they work with the resources they have. The result is a government workforce that is exponentially more creative and productive. For more information visit www.Empower.ai.

Empower AI is proud to be recognized as a 2022 Military Friendly Employer by Viqtory the publisher of G.I. Jobs. This designation reflects the company’s commitment to hiring and supporting active-duty and veteran employees.

Responsibilities:

ESSENTIAL FUNCTIONS BY LEVEL:


MEDICAL REVIEWER V

  • Reviews and analyzes sampled Medicaid claims using associated medical records to make payment determinations based on coverage coding utilization of services and practice guidelines
  • Makes medical necessity determinations utilizing clinical review judgment in accordance with PERM policies and contract responsibilities
  • Serves as a resource for medical review specialists involving coverage coding and medical necessity issues
  • Performs the first and secondlevel of medical review in determination of claims payment review
  • Conducts in-depth claims analysis utilizing ICD-9-CM ICD-10-CM CPT-4 APR-DRG and HCPCS Level II coding principles
  • Provides medical review specialist production assignments (quantity and type of claim review) to the Medical record Department as needed
  • Provides medical review specialist claims production reports to the Medical Review Manager applying appropriate variance (fringe hours QA meeting time etc.) statistics as needed
  • Conducts medical record audits to determine the medical necessity and/or appropriateness of medical treatment using CMS and other national guidelines as well as local medical review policies
  • Provides research and updates to specialty claims review and review team needs
  • Provides electronic documentation of findings and conclusions with determinations of claims payment appropriateness in review tool fields
  • Provides training to integral staff and subcontractors for special studies as well as regular project claims review
  • Complies with departmental policies and procedures
  • Attends departmental or required education and training programs
  • Completes other projects or duties as assigned by the Medical Review Manager

Qualifications:

MINIMUM REQUIREMENTS:


V
  • Graduate from an accredited Registered Nurse (RN) school (Associate’s degree or diploma based) or Bachelor’s Degree (preferred) with active state licensure
  • Excellent oral and written communication skills
  • Organization and time management skills
  • Leadership skills to guide and mentor the work of less experienced personnel
  • Interpersonal skills
  • Problem solving and analytical skills
  • Ability to work in a team environment
  • Ability to keep sensitive and confidential material private
  • Ability to implement the operational strategies and procedures that will help achieve the overall quality and production goals of the Medical Review unit
  • At least four (4) years of clinical experience in medical or surgical nursing
  • Medicaid and/or CHIP claim review experience
  • Demonstrated knowledge of ICD-9CM CPT-4 and HCPCS Level II coding applications desirable (certification preferred)

EXPERIENCE REQUIRED BY LEVEL:
  • V: 10 – 15 Years

PREFERRED EDUCATION AND EXPERIENCE:
  • Medical claim review experience is desirable
  • Active professional coding certification

PHYSICAL REQUIREMENTS:

This position requires the ability to perform the below essential functions:

  • Sitting for long periods

About Empower AI:

It is the policy of Empower AI to provide equal opportunity in recruiting hiring training and promoting individuals in all job categories without regard to race color religion national origin gender age disability genetic information veteran status sexual orientation gender identity or any other protected class or category as may be defined by federal state or local laws or regulations. In addition we affirm that all compensation benefits company-sponsored training educational assistance social and recreational programs are administered without regard to race color religion national origin gender age disability genetic information veteran status sexual orientation or gender identity. It is our firm intent to support equal employment opportunity and affirmative action in keeping with applicable federal state and local laws and regulations. Empower AI is a VEVRAA Federal Contractor.

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