Medical Reviewer III (Medicaid)

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MEDICAL REVIEWER III

Conducts medical record audits to determine the medical necessity and/or appropriateness of medical treatment as defined by the Statement of Work and CMS directives as well as state and local specific regulations
• Conducts in-depth claims analysis utilizing extensive knowledge of medical terminology, ICD-9-CM, ICD-10-CM, CPT-4, APR-DRG, and HCPCS Level II coding principles
• Utilizes payer guidelines for coverage determinations
• Makes determination of the claim's medical appropriateness utilizing clinical review judgment in accordance with PERM policies and contract responsibilities
• Provides electronic documentation of findings and conclusions with determinations of claims payment appropriateness
• Reviews the Master Policy List and the MR questionnaire for each State prior to the review of claims for that State
• Ensures the MR department's compliance with quality management system and ISO requirements
• Utilizes electronic documentation and spreadsheets to track personal productivity and claim determination trends
• Participates in QA and IRR monitoring as requested
• Complies with departmental policies and procedures
• Comply with QA and productivity benchmarks established by the PERM MR department
• Attends departmental or required education and training programs
• Effectively communicates with management and colleagues
• Performs other projects or duties as assigned by the Senior Medical Review Specialist or Medical Review Manager

Requirements:

• Active RN state licensure
• 4-9 years experience
• At least four (4) years clinical experience in a medical/surgical setting
• At least two (2) years of medical record audit experience
• Familiarity with Medicaid and/or CHIP program
• Critical thinking and analytical skills
• Highly developed organization and time management skills
• Ability to work in a telecommute team environment
• Ability to keep sensitive and confidential material private
• Must have no adverse actions pending or taken against him/her by any State or Federal licensing board or program

Preferred Education and Experience:

• Active professional coding certification or the ability to obtain certification within eighteen (18) months of employment

• Demonstrated knowledge of ICD-9-CM, ICD-10-CM, CPT-4, APR-DRG, and HCPCS Level II coding principles
• Familiarity with CERT, DOJ, ZPIC, UPIC, or PERM claim audits

Physical Requirements:

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

• Sitting for long periods

All hiring and promotion decisions at Empower AI are based on merit to bring the best talent available to contribute to our firm's overall success. It is the policy of Empower AI not to discriminate against any applicant for employment, or employee because of age, color, sex, disability, national origin, race, religion, or veteran status. Empower AI is a VEVRAA Federal Contractor.