Medical Reviewer III (Medicaid)
Overview:
Empower AI is AI for government. Empower AI gives federal agency leaders the tools to elevate the potential of their workforce with a direct path for meaningful transformation. Headquartered in Reston, Va., Empower AI leverages three decades of experience solving complex challenges in Health, Defense, and Civilian missions. Our proven Empower AI Platform® provides a practical, sustainable path for clients to achieve 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.Empower.ai.
Empower AI 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
Comply 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 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
Preferred Education and Experience:
Active professional coding certification or the ability to obtain certification within 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 perform the below essential functions:
Sitting for long periods
About Empower AI:
All hiring and promotion decisions at Empower AI are based on merit to bring the best talent available to contribute to our firms overall success. It is the policy of Empower AI not to discriminate against any applicant for employment, or employee because of age, color, sex, disability, national origin, race, religion, or veteran status. Empower AI is a VEVRAA Federal Contractor.
Apply Now
Empower AI is AI for government. Empower AI gives federal agency leaders the tools to elevate the potential of their workforce with a direct path for meaningful transformation. Headquartered in Reston, Va., Empower AI leverages three decades of experience solving complex challenges in Health, Defense, and Civilian missions. Our proven Empower AI Platform® provides a practical, sustainable path for clients to achieve 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.Empower.ai.
Empower AI 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
Comply 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 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
Preferred Education and Experience:
Active professional coding certification or the ability to obtain certification within 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 perform the below essential functions:
Sitting for long periods
About Empower AI:
All hiring and promotion decisions at Empower AI are based on merit to bring the best talent available to contribute to our firms overall success. It is the policy of Empower AI not to discriminate against any applicant for employment, or employee because of age, color, sex, disability, national origin, race, religion, or veteran status. Empower AI is a VEVRAA Federal Contractor.
Apply Now