Medical Reviewer III (Medicare/DRG)

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 DRG.
• Performs first 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 DRG claims.
• Meet quality and production standards.
• Ensure departmental compliance with quality management systems and ISO requirements.
• Completes other projects or duties assigned by the Medical Review Lead Specialist.

Qualifications

• 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 of Durable Medical Equipment.
• At least three (3) years clinical experience as a Registered Nurse.
• Minimum two (2) years federal and local policy applications in relation to Medicare insurance procedures for medical necessity for Physician Office practices, Laboratory, and Ambulance Services.
• Current licensure as a Registered Nurse in one or more of the 50 states or D.C.
• Able to keep sensitive and confidential material private.
• No adverse actions pending or taken against him/her by any State or Federal licensing board or program and no conflict of interest (COI).
• Prior work as a Medicare Contractor Medical Review Nurse or Commercial Insurance.
• 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