Medical Review Specialist V (Medicare Part A Claims Lead)

Empower AI: As a Medical Review Specialist V - Part A Lead (Medical Reviewer V) for Empower AI Company, you will perform Medicare comprehensive medical record and claims review to make payment determinations for Medicare PART A (excluding DRG). These claim specialties include Home Health (HH), Hospice, End Stage Renal Disease (ESRD), Outpatient Rehabilitation Facilities (ORF), Outpatient Hospital, Rural Health Clinics, Skilled Nursing Facility (SNF) Services and others. Perform projects or duties as assigned as the Lead Medical Review Specialist. You will serve as a critical component in meeting our mission of providing excellent services to our clients. Your experience ensures an exciting and rewarding opportunity to be at the forefront of activities related to implementing healthcare reform on a national level. In assuming this position, you will be a critical contributor to meeting Empower AI's mission: To deliver innovative, cost-effective solutions and services that enable our customers to rapidly adapt to dynamic environments.

Highlights of Responsibilities:

• 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 Outpatient Facilities and Services.
• Serves as a resource for medical review specialists involving coverage, coding, and medical necessity issues
• Performs the third level of Medical Review in determination of claims payment review when the first and second level medical review determinations are in opposition
• Provides training to integral staff and subcontractors for special studies as well as regular project claims 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.
• Supervising the analysis of provider and service specific claims to identify error.
• Meeting quality and production standards.
• Ensuring departmental compliance with quality managements system and ISO requirements.
• Completes other projects or duties as assigned by the Medical Review Manager

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 claims knowledge either from billing, reviewing, or processing.
• At least ten (10) years clinical experience as a Registered Nurse.
• At least one (1) year supervisory experience
• Minimum four (4) years federal and local policy applications in relation to Medicare insurance procedures for medical necessity for Outpatient Facilities and Services.
• 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).
• Must have and maintain a valid state driver’s license for the state of residence.

Preferred Education and Experience:

• HH, Hospice, SNF RN clinical and/or administrative nursing experience
• Prior work as a Medicare Contractor Medical Review Nurse or Commercial Insurance Outpatient Facilities and Services.
• Optional - Bilingual (Spanish) - Fluency in reading and understanding Spanish language especially as it relates to medical records is a plus!

Physical Requirements:

This position requires the ability to perform the below essential functions:

• Sitting for long periods
• Standing for long periods
• Ambulate throughout an office
• Ambulate between several buildings
• Stoop, kneel, crouch, or crawl as required

Job Type: Full-time

Schedule:

• Monday to Friday

Work Location: Remote