Medical Reviewer V

Responsibilities

• Reviews and analyzes sampled Medicare claims using associated medical records, to make payment determinations based on coverage, coding, utilization of services and practice guidelines.
• Makes medical necessity determinations utilizing clinical review judgment in accordance with the CERT Program policies and contract responsibilities.
• Serves as a resource for medical review specialists involving coverage, coding, and medical necessity issues.
• Performs third level of Medical Review in determination of claims payment review when the first and second level medical review determinations are in opposition.
• Can perform first or second level medical review as needed.
• Conducts in-depth claims analysis utilizing ICD-9-CM, ICD-10-CM, CPT-4, and HCPCS Level II coding principles.
• Applies the interpretation of ANSI Reason Codes, Revenue Codes, timely MAC Edits and Audit codes and other Medicare billing formats in determination of appropriate billing submissions and reimbursement.
• Conducts medical record audits to determine the medical necessity and/or appropriateness of medical treatment using CMS and other national guidelines, as well as local medical review policies.
• Provides research and updates to specialty claims review and review team needs.
• Provides electronic documentation of findings and conclusions with determinations of claims payment appropriateness in review tool fields.
• Reviews and completes referred level claim reviews in accordance to production standards for special studies as well as regular project claims for end of reporting requirements.
• Aids in training to integral staff for special studies as well as regular project claims review.
• Aids as needed for QC Panel reviews.
• Prepares review for IRR Panel as needed.
• Attends Medical Review Lead meetings when necessary and invited.
• Assists with questions from medical records or customer service with regard to specific claim type.
• Complies with Program Integrity Manual (PIM) and Statement of Work (SOW) guidelines and CMS directives and regulations pertaining to integrity, fraud, overpayments, and the handling and disclosure of information.
• Complies with departmental policies and procedures.
• Communicates internally with all levels of the CERT Program.
• Attends departmental or required education and training programs.
• Completes other projects or duties as assigned by the Medical Review Manager.

Qualifications

• Bachelor's degree – OR - Associate's degree – OR - Diploma in Nursing.
• At least three (3) years claims knowledge either from billing, reviewing, or processing.
• At least three (3) years clinical experience as a Registered Nurse.
• Minimum ten (10) years federal and local policy applications in relation to insurance procedures for medical necessity for skilled nursing facility and Part A claim reimbursements.
• 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).