Medical Review Specialist III (Medicare Home Health and Hospice)

NCI; United States; Remote; USD 60,000 - 100,000; Full time

Job summary

An established industry player is seeking a Medical Review Specialist III to join their remote team. In this critical role, you will conduct comprehensive reviews of Medicare claims, ensuring compliance with insurance coverage and coding guidelines. Your expertise will help shape the future of healthcare by ensuring quality and accuracy in medical reviews. This position offers the opportunity to work on meaningful projects that directly impact patient care and healthcare reform. If you are a dedicated Registered Nurse with a passion for improving healthcare services, this role is perfect for you, providing a rewarding career path in a supportive environment.

Qualifications

• Must be a Registered Nurse with at least two years of claims knowledge.
• Minimum four years of clinical experience as a Registered Nurse.

Responsibilities

• Perform comprehensive medical record and claims review for Medicare.
• Conduct in-depth claims analysis utilizing coding principles.

Skills

ICD-10-CM coding

CPT-4 coding

HCPCS Level II coding

Clinical judgment

Claims analysis

Confidentiality

Education

Bachelor's degree in Nursing

Associate's degree in Nursing

Diploma in Nursing

Tools

Microsoft Office Suite

Electronic health information imaging

Job description

Medical Review Specialist III (Medicare Home Health and Hospice)

Pay Competitive

Location Remote

Employment type Full-Time

Job Description

• Req#: 7252

Overview

Empower AI is AI for government. 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. For more information, visit www.Empower.ai.

Empower AI is proud to be recognized as a 2022 Military Friendly Employer by Viqtory, the publisher of G.I. Jobs. This designation reflects the company’s commitment to hiring and supporting active-duty and veteran employees.

Responsibilities

Empower AI: As a Medical Review Specialist III (Medical Reviewer III) you will primarily perform Medicare comprehensive medical record and claims review to make payment determinations for Medicare PART A- Home Health and Hospice. Additional Part A services may be assigned such as End Stage Renal Disease (ESRD), Outpatient Rehabilitation Facilities (ORF), Outpatient Hospital, Rural Health Clinics, and others. Perform projects or duties as assigned as a Medical Review Specialist. You will serve as a critical component in meeting our mission of providing excellent services to our clients. Your experience ensures an exciting and rewarding opportunity to be at the forefront of activities related to implementing healthcare reform on a national level.

Highlights of 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 A, Home Health and Hospice, Outpatient Facilities and Services.
• Perform first and second level of Medical Review in determination of claims payment review.
• Conduct 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 Part A claims.
• Meeting quality and production standards.
• Ensuring departmental compliance with quality management system and ISO requirements.
• Completes other projects or duties as assigned by the Medical Review Lead Specialist.

Qualifications

MINIMUM REQUIREMENTS:

• Must be a Registered Nurse obtained by either a Bachelor's degree – OR - Associate's degree – OR - Diploma in Nursing. At least two (2) years claims knowledge either from billing, reviewing, or processing in a home health or hospice setting.
• At least four (4) 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 Outpatient Facilities and Services.
• 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).
• Must have and maintain a valid state driver’s license for the state of residence.

Preferred Education and Experience:

• Home Health, Hospice, Outpatient Services RN clinical and/or administrative nursing experience.
• Prior work as a Medicare Contractor Medical Review Nurse or Commercial Insurance Hospice, Outpatient Services RN clinical and/or administrative nursing experience.
• Optional - Bilingual (Spanish) - Fluency in reading and understanding Spanish language especially as it relates to medical records is a plus!

Physical Requirements:

• Sitting for long periods.
• Standing for long periods.
• Ambulate throughout an office.
• Ambulate between several buildings.
• Stoop, kneel, crouch, or crawl as required.

About Empower AI

It is the policy of Empower AI to provide equal opportunity in recruiting, hiring, training, and promoting individuals in all job categories without regard to race, color, religion, national origin, gender, age, disability, genetic information, veteran status, sexual orientation, gender identity, or any other protected class or category as may be defined by federal, state, or local laws or regulations. In addition, we affirm that all compensation, benefits, company-sponsored training, educational assistance, social, and recreational programs are administered without regard to race, color, religion, national origin, gender, age, disability, genetic information, veteran status, sexual orientation, or gender identity. It is our firm intent to support equal employment opportunity and affirmative action in keeping with applicable federal, state, and local laws and regulations. Empower AI is a VEVRAA Federal Contractor.