Medical Reviewer III (Medicaid)

Empower AI; United States; Remote; USD 70,000 - 110,000; Full time

Job summary

An established industry player is seeking a Medical Reviewer III to join their remote team. This role is pivotal in conducting medical record audits to ensure compliance with healthcare regulations and guidelines. The ideal candidate will possess a strong background in medical coding and critical thinking skills, enabling them to analyze claims effectively. This position offers the opportunity to work within a supportive environment that values the contributions of its team members, fostering both personal and professional growth. Join a company committed to transforming government services through innovative AI solutions.

Qualifications

• Active RN state licensure is required.
• 4-9 years of experience in healthcare is essential.
• Experience in medical record audits is preferred.

Responsibilities

• Conducts medical record audits for treatment appropriateness.
• Utilizes extensive knowledge of medical coding principles.
• Documents findings and ensures compliance with quality standards.

Skills

Critical thinking

Analytical skills

Organization skills

Time management

Medical terminology knowledge

ICD-9-CM coding

ICD-10-CM coding

CPT-4 coding

APR-DRG coding

HCPCS Level II coding

Education

Active RN state licensure

4-9 years experience

Clinical experience in a medical/surgical setting

Medical record audit experience

Job description

Medical Reviewer III (Medicaid)

Job ID

2025-8076

Job Locations

US-Remote

Category

Healthcare / Biotechnology

Type

Regular Full-Time

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 2024 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

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

Qualifications

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

Preferred Education and Experience:

• 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

Physical Requirements:

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

• Sitting for long periods

About Empower AI

All hiring and promotion decisions at Empower AI are based on merit to bring the best talent available to contribute to our firm's overall success. It is the policy of Empower AI not to discriminate against any applicant for employment, or employee because of age, color, sex, disability, national origin, race, religion, or veteran status. Empower AI is a VEVRAA Federal Contractor.

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