Medical Review Specialist III (DRG Claims)

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.

Responsibilities

As a Medical Review Specialist III (Medical Reviewer III), you will perform Medicare comprehensive medical record and claims review to make payment determinations for Medicare DRG Inpatient Acute Hospital admissions. You will serve as a critical component in meeting our mission of providing excellent services to our clients and contribute to implementing healthcare reform on a national level.

• Perform comprehensive medical record and claims review to make payment determinations based on insurance coverage, coding, and utilization of services and practice guidelines for Inpatient Acute Hospital admissions (DRG reimbursed).
• Utilize electronic health information imaging and input medical review decisions via electronic database module.
• Use internet and intranet sources for policy verification.
• Utilize Microsoft Office suite and other software templates for claims review.
• Make clinical judgment decisions based on clinical experience when applicable.
• Review Medicare DRG claims and supervise the analysis of provider and service-specific claims to identify errors.
• Meet quality and production standards.
• Ensure departmental compliance with quality management system and ISO requirements.
• Perform projects or duties as assigned by the Lead Medical Review Specialist.

Requirements

• Bachelor's degree – OR - Associate's degree – OR - Diploma in Nursing.
• At least four (4) years of claims knowledge either from billing, reviewing, or processing.
• At least four (4) years of medical-surgical clinical experience as a Registered Nurse.
• Minimum four (4) years of federal and local policy applications in relation to insurance procedures for medical necessity, including the Two Midnight Rule in DRG acute inpatient hospital admissions.
• Current licensure as a Registered Nurse in one or more of the 50 states or D.C.
• Ability to maintain confidentiality of sensitive material.
• No adverse actions pending or taken by any State or Federal licensing board or program and no conflict of interest (COI).
• Must have and maintain a valid state driver’s license for the state of residence.

Qualifications

Preferred Education and Experience:

• Prior utilization review experience in the inpatient setting.
• ICD-10-CM, PCS, CPT-4 coding knowledge.
• Prior work as a Medicare Contractor Medical Review Nurse.
• Bilingual (Spanish) – fluency in reading and understanding Spanish language, especially as it relates to medical records, is a plus.

Skills

• Sitting and standing for long periods.
• Ability to ambulate throughout an office and between several buildings.