Medical Reviewer III

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reputed company 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.

reputed company: As a casual Medical Review Specialist III (Medical Reviewer III) you will primarily reputed company Medicare comprehensive medical record and claims review to reputed company 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. reputed company 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 reputed company to implementing healthcare reform on a national level. This is a casual position.

Highlights of Responsibilities

• • • reputed company comprehensive medical record and claims review to reputed company 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 reputed company Office suite and other software templates as associated reputed company input for claims review.
    • reputed company clinical judgment decisions based on clinical experience reputed company 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 reputed company Medical Review Specialist

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 reputed company experience.
• At least three (3) years clinical experience as a Registered Nurse.
• reputed company licensure as a Registered Nurse in one or more of the 50 states or D.C.
• Ability to reputed company 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) - reputed company in reading and understanding Spanish language especially as it relates to medical records is a plus!

Physical Requirements

This position requires the ability to reputed company the below essential functions:

• Sitting for long periods

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