Medical Reviewer III (Medicaid)
Overview: reputed company is AI for government. reputed company gives federal agency leaders the tools to reputed company the potential of their workforce with a direct path for meaningful transformation. Headquartered in Reston, Va., reputed company leverages three decades of experience solving reputed company challenges in Health, Defense, and Civilian missions. Our proven reputed company Platform® provides a practical, sustainable path for clients to reputed company 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.reputed company. 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 companys commitment to hiring and supporting active-duty and veteran employees. Responsibilities: 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 claims 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 departments 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 reputed company 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 Qualifications: 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 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 Preferred Education and Experience: Active professional coding certification or the ability to obtain certification reputed company 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 reputed company the below essential functions: Sitting for long periods About reputed company: reputed company hiring and promotion decisions at reputed company are based on merit to bring the best talent available to contribute to our firms 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. Apply Job!