Medicaid Medical Review RN (Medical Reviewer III)

Responsibilities

• Reviews information contained in Standard 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 Medicaid payment policies.
• Utilizes extensive knowledge of medical terminology, ICD-9-CM, ICD-10-CM HCPCS Level II and CPT coding along with analysis and processing of Medicare claims.
• Utilizes Medicare/Medicaid and Contractor guidelines for coverage determinations.
• Collaborates with PI Investigators to compile the written Investigative Summary Report upon completion of the records review.
• Incorporates leadership and communication skills to work with physicians and other health professionals as well 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 quality assurance goal of 98% accuracy.
• Maintains chain of custody on all documents and follows all confidentiality and security guidelines.

Requirements

• 2 years minimum experience with a state Medicaid agency or Managed Care Organization focused in Medicaid.
• 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 signs of fraud, waste or abuse are noted.
• Advanced knowledge of medical terminology and experience in the analysis and processing of Medicare claims, utilization review/quality 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.
• Knowledge of and the ability to correctly identify, Medicare and Medicaid coverage guidelines.
• Excellent verbal and written communication skills with an ability to write professional summary reports.
• Knowledge of and ability to use Microsoft Word, Excel, and Internet applications.
• Able to efficiently organize and manage workload and assignments.
• Must have and maintain a valid driver's license for the state of residence as on-site audits are part of the role as a nurse reviewer.

Qualifications

• Graduate from an accredited school of nursing and have an active license as a Registered Nurse (RN) required.
• Preference given to BSN or higher prepared nurses with recent medical review claims experience in Medicare or Medicaid reviews.

Benefits

• Medical, Dental, Vision plans
• Life, LTD and STD paid by the employer
• 401(k) with company match up to 4%
• Tuition assistance after 1 year of service

Pay

The salary range for this role is $65,000 to $70,000 annually. This is the lowest to highest salary we in good faith believe we would pay for this role at the time of this posting. We may ultimately pay more or less than the posted range, and the range may be modified in the future.

About Us

CoventBridge Group is the global leader in full-service investigations providing Surveillance, SIU and Compliance, Claims Investigation, Counter-Fraud Programs, Desktop Investigations, Social Media, Record Retrieval, Canvasses and Vendor Management programs. The company provides top tier data privacy and security practices, deploys robust case management technology customized to clients’ needs and delivers worldwide coverage via its 1000 employees and affiliates worldwide. CoventBridge is an equal opportunity employer. We evaluate qualified applicants without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, caste, disability, veteran status, and other legally protected characteristics and maintains a drug-free workplace. CoventBridge is committed to the full inclusion of all qualified individuals.