Medical Reviewer III

Job Description: • Perform comprehensive medical record and claims review to make 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 Microsoft Office suite and other software templates as associated source input for claims review. • Make clinical judgment decisions based on clinical experience when 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 Lead 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 related experience. • At least three (3) years clinical experience as a Registered Nurse. • Current licensure as a Registered Nurse in one or more of the 50 states or D.C. • Ability to keep 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) - Fluency in reading and understanding Spanish language especially as it relates to medical records is a plus! Benefits: • Empower AI is proud to be recognized as a 2024 Military Friendly Employer by Viqtory, the publisher of G.I. Jobs. • Flexible work arrangements