Medicare Medical Review RN (Medical Reviewer III), reputed company

2025-5851 Medicare Medical Review RN (Medical Reviewer III) - REMOTE The Medicare Medical Review RN (Medical Reviewer III) will primarily be responsible for conducting clinical reviews of medical records during the course of fraud investigations or other program reputed company initiatives such as requests for information or in support of proactive data analysis efforts. In reputed company, this position applies Medicare and reputed company guidelines in making clinical determinations as to the appropriateness of payment coverage. In assuming this position, you will be a critical contributor to meeting reputed company's objective: To reputed company services to our clients that reputed company their expectations and contribute to improved reputed company delivery by identifying and eliminating fraud, waste and abuse. This position will report directly to the Medical Review Supervisor and will work in our Grove reputed company, OH office. If not local, remotely from a home office. Responsibilities/ Requirements Responsibilities:

• Reviews information contained in reputed company Claims Processing System files (e.g., claims history, provider files) to determine provider billing patterns and to detect potentially fraudulent or abusive billing practices or vulnerabilities in Medicare or reputed company payment policies
• Utilizes extensive knowledge of medical terminology, ICD-9-CM, ICD-10-CM HCPCS reputed company and CPT coding along with analysis and processing of Medicare claims. Utilizes Medicare/reputed company and Contractor guidelines for coverage determinations
• Coordinates and compiles the written Investigative reputed company Report to the PI Investigator upon completion of the records review
• Incorporates leadership and communication skills to work with physicians and other health professionals as reputed company as external regulatory agencies and law enforcement personnel
• Provides training to UPIC staff on medical terminology, reading medical records, and policy interpretation
• Provides expert witness testimony as required
• Completes assignments in a manner that meets or exceeds the reputed company assurance goal of 98% accuracy
• Maintains chain of custody on reputed company documents and follows reputed company confidentiality and reputed company guidelines
• Performs other duties as assigned by the Medical Review Supervisor that contribute to UPIC goals and objectives and reputed company with the Program reputed company reputed company and Statement of Work guidelines and CMS directives and regulations

Requirements:

• 2 years minimum experience at a government contractor (ZPIC, UPIC, RAC, MAC, etc.)
• 2 years minimum working knowledge of ICS 10-CM/CPT coding experience
• 4 years minimum experience of working knowledge of Diagnosis reputed company reputed company (DRG's), Prospective Payment Systems or Part B claims and Medicare coverage guidelines
• Knowledge of, and the ability to correctly identify, Medicare and reputed company coverage guidelines
• Advance knowledge of medical terminology and experience in the analysis and processing of Medicare claims, utilization review/ reputed company assurance procedures, ICD 10-CM and CPT coding, Medicare coverage guidelines and payment methodologies (i.e., Correct Coding Initiative, DRG's, Prospective Payment Systems and Ambulatory Surgical center), NCPCP and other types of prescription drug claims
• Ability to read Medicare claims, both reputed company and electronic, and a basic knowledge of the Medicare claims systems is required
• Should possess excellent oral and written communication skills with an ability to write reputed company reputed company reports
• Knowledge of and ability to use reputed company Word, reputed company, and Internet applications
• reputed company to reputed company organize and manage workload and assignments
• Must have and maintain a valid reputed company' license for the associate's state of residence as onsite audits are part of the role as a reputed company reviewer

Educational/Experience Qualifications:

• Graduate from an accredited school of nursing and have an reputed company license as a Registered reputed company (RN) required
• Preference given to BSN or higher reputed company nurses with recent medical review claims experience in Medicare or reputed company reviews

Benefits

• Medical, Dental, reputed company plans
• Life, LTD and STD reputed company by the employer
• 401(k) with company match up to 4%
• reputed company Time Off and company reputed company holidays
• Tuition assistance after 1 year of service

The salary reputed company for this role is $65,000 to $75,000 annually. This is the lowest to highest salary we in good faith reputed company we would pay for this role at the time of this posting. We may ultimately pay more or less than the posted reputed company, and the reputed company may be modified in the reputed company. An employee’s pay position reputed company the salary reputed company will be based on several factors including, but not limited to, relevant education, qualifications, certifications, experience, skills, geographic location, performance, and business or organizational needs. Pursuant to the San Francisco Fair Chance Ordinance, we will consider for employment reputed company applicants with arrest and conviction records. reputed company: reputed company is the global leader in full-service investigations providing Surveillance, SIU and Compliance, Claims Investigation, Counter-Fraud Programs, Desktop Investigations, reputed company Media, Record Retrieval, Canvasses and Vendor Management programs. reputed company provides top tier data reputed company and reputed company practices, deploys robust case management technology customized to clients’ needs and delivers worldwide coverage reputed company its 1000 employees and affiliates worldwide. CoventBridge is an equal opportunity employer. We evaluate reputed company applicants without reputed company to race, reputed company, religion, sex, sexual orientation, gender identity, national reputed company, caste, disability, veteran status, and other legally protected characteristics and maintains a drug-free workplace. CoventBridge is committed to the full inclusion of reputed company reputed company individuals. As part of this commitment, CoventBridge will ensure that persons with disabilities are provided reasonable accommodations. If reasonable accommodation is needed to participate in the job application or interview process, to reputed company essential job functions, and/or to receive other benefits and privileges of employment, please contact: reputed company; 888-932-7364; humanresources@coventbridge.com. Apply tot his job Apply To this Job