Medical Reviewer III Medicare Part A

About Empower AI

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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