Medical Reviewer III (Medicare Part A)
Empower AI · United States
- Hybrid
- Full-time
- $75,000 / year
- United States
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Job highlights
- Review Medicare Part A claims for payment determinations.
- Analyze claims using coding and utilization guidelines.
- Utilize electronic health records and databases.
- Requires Registered Nurse with 4+ years experience.
- Casual position with remote work potential.
About the role
About Empower AI
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 2024 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
As a casual Medical Review Specialist III (Medical Reviewer III) you will primarily perform Medicare comprehensive medical record and claims review to make payment determinations for Medicare PART A. Part A services include End Stage Renal Disease (ESRD), Outpatient Rehabilitation Facilities (ORFs), Rural Health Clinics (RHCs), Critial Access Hospitals (CAHs) and others. Perform projects or duties as assigned as a Medical Review Specialist. You will serve as a critical component in meeting our mission of providing excellent services to our clients. Your experience ensures an exciting and rewarding opportunity to be at the forefront of activities related to implementing healthcare reform on a national level. This is a casual position.
Highlights of Responsibilities:
- Perform comprehensive medical record and claims review to make payment determinations based on Insurance coverage, coding, and utilization of services and practice guidelines for Medicare A, Outpatient Facilities and Services.
- Performs first and second level of Medical Review in determination of claims payment review.
- Conducts in-depth claims analysis utilizing ICD-10-CM, CPT-4, and HCPCS Level II coding principles.
- Utilize electronic health information imaging and input medical review decisions by electronic database module.
- Utilize internet and intranet sources for policy verification.
- Utilize Microsoft Office suite and other software templates as associated source input for claims review.
- Make clinical judgment decisions based on clinical experience when applicable.
- Responsible for review of Medicare Part A claims.
- Meeting quality and production standards.
- Ensuring departmental compliance with quality managements system and ISO requirements.
- Completes other projects or duties as assigned by the Lead Medical Review Specialist.
Qualifications
Requirements:
- Must be a Registered Nurse obtained by either a Bachelor's degree – OR - Associate's degree – OR - Diploma in Nursing.
- At least four (4) years related experience.
- At least three (3) years clinical experience as a Registered Nurse.
- Current licensure as a Registered Nurse in one or more of the 50 states or D.C.
- 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 and must have no conflict of interest (COI).
Preferred Education and Experience:
- Medicare Part A RN clinical review.
- Minimum two (2) years federal and local policy applications in relation to Medicare insurance procedures for medical necessity for Outpatient Facilities and Services.
- Prior work as a Medicare Contractor Medical Review Nurse or Commercial Insurance Home Health RN review experience.
- Optional - Bilingual (Spanish) - Fluency in reading and understanding Spanish language especially as it relates to medical records is a plus!
Physical Requirements:
This position requires the ability to perform the below essential functions: Sitting for long periods
Key skills/competency
- Medical Review
- Medicare Part A
- Claims Analysis
- Registered Nurse
- Clinical Experience
- ICD-10-CM
- CPT-4
- HCPCS Level II
- Policy Application
- HIPAA Compliance
Skills & topics
- Medical Reviewer
- Medicare
- Claims Analysis
- Registered Nurse
- RN
- Healthcare
- Government Contracting
- Health Informatics
- ICD-10-CM
- CPT-4
- HCPCS
- Clinical Review
- Remote Job
- Casual Position
How to get hired
- Tailor your resume: Highlight RN experience and Medicare Part A knowledge.
- Showcase clinical skills: Emphasize your diagnostic and claims analysis abilities.
- Demonstrate coding expertise: Detail your proficiency with ICD-10-CM, CPT-4, HCPCS.
- Express interest clearly: Mention your understanding of government healthcare initiatives.
- Prepare for review: Be ready to discuss your clinical judgment and decision-making.
Technical preparation
Behavioral questions
Frequently asked questions
- What is Empower AI looking for in a Medical Reviewer III?
- Empower AI is seeking a Registered Nurse with at least four years of related experience, including three years of clinical experience as an RN. Key qualifications include current RN licensure, proficiency in medical record and claims review, and knowledge of Medicare Part A procedures, coding principles (ICD-10-CM, CPT-4, HCPCS Level II), and policy applications.
- Is this a remote or on-site position?
- The job description mentions Empower AI is headquartered in Reston, VA, but it does not explicitly state the work arrangement for this Medical Reviewer III position. Given the nature of the work, it is possible that remote or hybrid arrangements may be considered, especially for a 'casual' role.
- What are the key responsibilities of the Medical Reviewer III at Empower AI?
- The Medical Reviewer III will perform comprehensive Medicare Part A medical record and claims reviews to make payment determinations. This includes analyzing insurance coverage, coding, utilization, and practice guidelines, conducting first and second-level reviews, utilizing electronic health information systems, verifying policies, and making clinical judgment decisions.
- What is the difference between a casual and a full-time employee at Empower AI?
- The job posting specifies this is a 'casual' position. Casual employees typically work on an as-needed basis and may not receive the same benefits as full-time employees. The exact terms of 'casual' employment at Empower AI would need to be clarified during the application process.
- What specific medical coding knowledge is required for this role?
- A strong understanding of ICD-10-CM, CPT-4, and HCPCS Level II coding principles is essential for conducting in-depth claims analysis as a Medical Reviewer III.
- Does Empower AI prioritize hiring veterans for this role?
- Yes, Empower AI is recognized as a 2024 Military Friendly Employer and is a VEVRAA Federal Contractor, indicating a strong commitment to hiring and supporting active-duty and veteran employees.