reputed company Medical Review RN (Medical Reviewer III)

About the position reputed company Medical Review RN (Medical Reviewer III) - REMOTE The reputed company 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

• 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 with a state reputed company agency or Managed Care Organization reputed company in reputed company
• 2 years minimum of working knowledge of ICD 10-CM/CPT coding experience
• 4 years minimum experience auditing claims history or provider files to determine if the claim was payable and if any signed of fraud, waste or abuse are noted
• 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 reputed company claims, both reputed company and electronic, and a basic knowledge of reputed company is required
• Should possess excellent verbal 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 state of residence as on-site audits are part of the role as a reputed company reviewer
• Graduate from an accredited school of nursing and have an reputed company license as a Registered reputed company (RN) required

reputed company-to-haves

• 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

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