Medical Reviewer III (Medicare DME claims)
Empower AI · United States
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- Hybrid
- Full-time
- $95,000 / year
- United States
Job highlights
- Review Medicare DME claims and medical records.
- Determine payment based on coverage and guidelines.
- Utilize coding principles and electronic systems.
- Apply clinical judgment and meet production standards.
- Requires Registered Nurse with claims and clinical experience.
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 Medical Review Specialist III (Medical Reviewer III) for Empower AI, Inc., you will perform Medicare comprehensive medical record and claims review to make payment determinations for Medicare Durable Medical Equipment (DME). 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. In assuming this position, you will be a critical contributor to meeting Empower AI’s mission: To deliver innovative, cost-effective solutions and services that enable our customers to rapidly adapt to dynamic environments.
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 DME.
- Performs first and second level of Medical Review in determination of claims payment review.
- Conducts in-depth claims analysis utilizing ICD-10-CM, AMA-CPT, 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 DME claims.
- Meeting quality and production standards.
- Ensuring departmental compliance with quality management system and ISO requirements.
- Completes other projects or duties as assigned by the Medical Review Lead 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 claims knowledge either from billing, reviewing, or processing of Durable Medical Equipment.
- At least three (3) years clinical experience as a Registered Nurse.
- Minimum four (4) years federal and local policy applications in relation to Medicare insurance procedures for medical necessity for Physician Office practices, Laboratory, and Ambulance Services.
- 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:
- Physician Office, Hospital, Supplier, or Clinic providing DME equipment care/services.
- Prior work as a Medicare Contractor Medical Review Nurse or Commercial Insurance for DME.
- 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.
- Standing for long periods.
Key skills/competency
- Medical Review
- Medicare Claims
- Durable Medical Equipment (DME)
- Registered Nurse (RN)
- Claims Analysis
- ICD-10-CM
- AMA-CPT
- HCPCS Level II
- Policy Verification
- Clinical Judgment
Skills & topics
- Medical Reviewer
- Medicare
- DME Claims
- Registered Nurse
- Claims Analysis
- Health Insurance
- Medical Coding
- RN
- Healthcare
- Government Contracting
How to get hired
- Tailor your resume: Emphasize your RN experience, Medicare claims processing, and knowledge of DME.
- Highlight relevant skills: Showcase expertise in ICD-10-CM, CPT, HCPCS Level II, and policy application.
- Address qualifications directly: Ensure your application clearly demonstrates the required RN licensure and years of claims/clinical experience.
- Showcase compliance knowledge: Mention familiarity with quality management systems and ISO requirements if applicable.
- Prepare for interview questions: Be ready to discuss your clinical judgment and experience with Medicare insurance procedures.
Technical preparation
Master ICD-10-CM, CPT, and HCPCS Level II coding.,Practice using electronic health record systems.,Review Medicare DME policy guidelines thoroughly.,Familiarize with ISO quality management systems.
Behavioral questions
Describe a complex claim review you handled.,How do you handle conflicting policy information?,Discuss your experience making clinical judgments.,How do you manage production and quality standards?
Frequently asked questions
- What specific experience is required for the Medicare Claims Reviewer role at Empower AI?
- To be considered for the Medicare Claims Reviewer position at Empower AI, candidates must possess a Registered Nurse (RN) license and have at least four years of claims knowledge in Durable Medical Equipment (DME) processing, billing, or reviewing. Additionally, a minimum of three years of clinical RN experience and four years of experience applying federal and local Medicare insurance policies are necessary. Familiarity with medical necessity for various services like Physician Office practices, Laboratory, and Ambulance Services is also required.
- What are the primary responsibilities of a Medical Reviewer III at Empower AI?
- The primary responsibilities of a Medical Reviewer III at Empower AI involve performing comprehensive reviews of Medicare durable medical equipment (DME) claims and associated medical records. This includes making payment determinations based on insurance coverage, coding principles (ICD-10-CM, AMA-CPT, HCPCS Level II), and utilization guidelines. The role also entails performing first and second level claim reviews, utilizing electronic systems, verifying policies, and making clinical judgment decisions when appropriate, all while meeting quality and production standards.
- What kind of clinical judgment is expected in this Medicare Claims Reviewer job?
- As a Medical Reviewer III at Empower AI, clinical judgment is expected when applicable, drawing upon your experience as a Registered Nurse. This involves assessing the medical necessity and appropriateness of Durable Medical Equipment (DME) based on the patient's condition and the provided documentation, in alignment with Medicare guidelines and insurance coverage policies. Your clinical background helps in making informed decisions when claim details or documentation require nuanced interpretation.
- Does Empower AI require specific software skills for the Medicare Claims Reviewer position?
- Yes, Empower AI requires specific software skills for the Medicare Claims Reviewer role. Candidates will need to be proficient in utilizing electronic health information imaging systems and inputting medical review decisions via an electronic database module. Familiarity with the Microsoft Office suite and other relevant software templates used for claims review is also essential. Additionally, the ability to use internet and intranet sources for policy verification is expected.
- What makes Empower AI a good employer for military veterans?
- Empower AI demonstrates a strong commitment to hiring and supporting active-duty military personnel and veterans. This is evidenced by their recognition as a 2024 Military Friendly Employer by Viqtory. They base all hiring and promotion decisions on merit, ensuring a fair environment for all candidates, including veterans, and fostering a workplace that values their unique skills and experiences.
- How does Empower AI approach diversity and inclusion in its hiring practices for the Medicare Claims Reviewer role?
- Empower AI is committed to a diverse and inclusive workplace. Their policy is not to discriminate against any applicant or employee based on age, color, sex, disability, national origin, race, religion, or veteran status. As a VEVRAA Federal Contractor, they actively seek to bring the best talent to contribute to their firm’s success, ensuring that merit is the basis for all hiring and promotion decisions.