MEDICAL REVIEWER III

• Conducts medical record audits to determine the medical necessity and/or appropriateness of medical treatment as defined by the Statement of Work and CMS directives as well as state and local specific regulations
• Conducts in-depth claims analysis utilizing extensive knowledge of medical terminology, ICD-9-CM, ICD-10-CM, CPT-4, APR-DRG, and HCPCS Level II coding principles
• Utilizes payer guidelines for coverage determinations
• Makes determination of the claim’s medical appropriateness utilizing clinical review judgment in accordance with PERM policies and contract responsibilities
• Provides electronic documentation of findings and conclusions with determinations of claims payment appropriateness
• Reviews the Master Policy List and the MR questionnaire for each State prior to the review of claims for that State
• Ensures the MR department’s compliance with quality management system and ISO requirements
• Utilizes electronic documentation and spreadsheets to track personal productivity and claim determination trends
• Participates in QA and IRR monitoring as requested
• Complies with departmental policies and procedures
• Comply with QA and productivity benchmarks established by the PERM MR department
• Attends departmental or required education and training programs
• Effectively communicates with management and colleagues
• Performs other projects or duties as assigned by the Senior Medical Review Specialist or Medical Review Manager

Requirements:

• 
  Active RN state licensure
• 4-9 years experience
• At least four (4) years clinical experience in a medical/surgical setting
• At least two (2) years of medical record audit experience
• Familiarity with Medicaid and/or CHIP program
• Critical thinking and analytical skills
• Highly developed organization and time management skills
• Ability to work in a telecommute team environment
• 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

• Active professional coding certification or the ability to obtain certification within eighteen (18) months of employment
• Demonstrated knowledge of ICD-9-CM, ICD-10-CM, CPT-4, APR-DRG, and HCPCS Level II coding principles
• Familiarity with CERT, DOJ, ZPIC, UPIC, or PERM claim audits

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

• 
  Sitting for long periods