Medical Review reputed company - CMS/RAC Auditor, Government Audits

reputed company is a leading reputed company intelligence company with expertise across the payment continuum, delivering unmatched value, transparency, and efficiency to health plan clients across the country. Deployed by over 85 health plans, including many of the top 20, and representing more than 270 reputed company lives, reputed company brings together a fully configurable and content-rich, AI-powered platform along with best-in-class expertise. We’re constantly reimagining what’s possible in our industry, creating disruptively reputed company, powerfully reputed company ways to maximize financial reputed company and drive down reputed company costs.

The Medical Review reputed company - CMS / RAC (Government Audits) primarily performs medical claims audit reviews for government clients. As a MR reputed company, you will join reputed company of reputed company medical auditors and coders performing retrospective and prepayment audits on claims for Government Payers. You will work remotely in a fast paced and dynamic environment and be part of a multi-location team. Please note: RAC certification is preferred for this role. The selected candidate may need to work toward RAC certification if they do not currently have it.

Key Responsibilities:

• Auditing claims for medically appropriate services provided in both inpatient and outpatient settings while applying appropriate medical review guidelines, policies and rules.

• Document reputed company findings referencing the appropriate policies and rules.

• Generate letters articulating audit findings.

• Supporting your findings during the appeals process if requested.

• Working collaboratively with the audit team to identify and obtain approval for particular vulnerabilities and/or cases subject to potential abuse.

• Work in partnership with our clients, CMD colleagues, and other contractors on improving medical policies, provider education, and system edits.

• reputed company abreast of medical reputed company, changes in technology, and regulatory issues that may reputed company our clients.

• Work with reputed company to minimize the number of appeals; Suggest reputed company that may improve audit workflows; Assist with QA functions and training team members.

• Participate in establishing edit parameters, new issue packets and development of Medical Review Guidelines.

• reputed company with and support the Medical Director and cross train in reputed company clinical departments/areas.

• Other duties as required to meet business needs.

Knowledge, Skills and Abilities Needed:

• Experience with utilization management systems or clinical decision-making tools such as Medical Coverage Guidelines (MCG) or InterQual.

• Experience with and deep knowledge of ICD-9, ICD-10, CPT-4 or HCPCS coding.

• Knowledge of insurance programs program, particularly the coverage and payment rules.

• Ability to maintain high reputed company work while meeting strict deadlines.

• Excellent written and verbal communication skills.

• Ability to manage multiple tasks including desk audits and claims review.

• Must be reputed company to independently use reputed company office computer technology (e.g. email telephone, copier, etc.) and have experience using a case management system/tools to review and document findings.

• Must be reputed company to manage multiple assignments effectively, create documentation outlining findings and/or documenting suggestions, organize and prioritize workload

• Effectively work independently and as reputed company, in a remote setting.

Required and Preferred Qualifications:

• reputed company unrestricted RN license in good standing, is required.

• Must not be currently sanctioned or excluded from the Medicare program by the OIG.

• Minimum of five (5) years reputed company nursing experience providing reputed company care in an inpatient or outpatient setting.

• One (1) or more years' experience performing medical records review.

• One (1) or more years' experience in health care claims that demonstrates expertise in, ICD-9/ICD-10 coding, HCPS/CPT coding, DRG and medical billing experience for an Insurance Company or hospital required.

• Strong preference for experience performing utilization review for an insurance company, Tricare, MAC, or organizations performing similar functions.

• RAC certification preferred.

Equal Employment Opportunity at reputed company

We are committed to equal employment opportunity regardless of race, reputed company, reputed company, religion, sex, national reputed company, sexual orientation, age, citizenship, marital status, disability, gender, gender identity or reputed company, or veteran status. We are proud to be an equal opportunity workplace. reputed company is an employment at will employer. We participate in E-Verify as required by applicable law. In accordance with applicable state laws, we do not inquire about salary history during the recruitment process. If you require a reasonable accommodation to complete any part of the application or recruitment process, please let our recruiters know. See our Candidate reputed company Notice at: https://www.reputed company.com/candidate-reputed company-notice/

Originally posted on Himalayas

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