MEDICAL REVIEWER V

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  Audits and analyzes sampled Medicaid and CHIP claims using associated medical records, to make payment determinations based on coverage, coding, utilization of services and practice guidelines
• Makes determination of the claim's medical appropriateness utilizing clinical review judgment in accordance with PERM policies and contract responsibilities
• Serves as a resource for medical review specialists involving coverage, coding, and medical audit issues
• Performs the first and second level of medical review in determination of claims payment review
• Conducts in-depth claims analysis utilizing ICD-9-CM, ICD-10-CM, CPT-4, APR-DRG, and HCPCS Level II coding principles
• Conducts medical record audits to determine the medical necessity and/or appropriateness of medical treatment using CMS and other national guidelines, as well as state and local medical review policies
• Prepares and presents claim determinations to CMS and state partners
• Provides electronic documentation of findings and conclusions with determinations of claims payment appropriateness
• Provides training to medical review staff and subcontractors for special studies as well as regular project claims review
• Complies with departmental policies and procedures
• Attends departmental or required education and training programs
• Provides medical review specialist claims production reports to the Medical Review Manager applying appropriate variance (fringe hours, QA, meeting time, etc.) statistics as needed
• Calculates and retains productivity and accuracy information for each individual team member, reports these numbers on the monthly spreadsheets, and yearly in the individuals yearly evaluation
• Carries out weekly 1:1 meetings and yearly evaluations with each assigned medical review team member.
• Completes other projects or duties as assigned by the Medical Review Manager

Requirements:

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  Graduate from an accredited Registered Nurse (RN) school (Associate's degree or diploma based) or Bachelor's Degree (preferred) with active state licensure
• 10-15 years experience
• Excellent oral and written communication skills
• Organization and time management skills
• Leadership skills to guide and mentor the work of less experienced personnel
• Critical thinking and analytical skills
• Ability to work in a telecommute team environment
• Ability to keep sensitive and confidential material private
• Ability to implement the operational strategies and procedures that will help achieve the overall quality and production goals of the Medical Review unit
• At least four (4) years of clinical experience in medical or surgical nursing
• At least two (2) years of formal management experience
• At least four (4) years of medical record audit experience
• Medicaid and/or CHIP claim review experience
• Demonstrated knowledge of ICD-9CM, CPT-4, and HCPCS Level II coding applications desirable (certification preferred)

• Experience with CERT, DOJ, ZPIC, UPIC, or PERM audits
• Active professional coding certification or the ability to obtain certification within eighteen (18) months of employment

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

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  Sitting for long periods