Medicaid Medical Review RN (Medical Reviewer III)

About the position

• Medicaid Medical Review RN (Medical Reviewer III) - REMOTE
• The Medicaid Medical Review RN (Medical Reviewer III) will primarily be responsible for conducting clinical reviews of medical records during the course of fraud investigations or other program integrity initiatives such as requests for information or in support of proactive data analysis efforts. In addition, this position applies Medicare and Medicaid guidelines in making clinical determinations as to the appropriateness of payment coverage.
• In assuming this position, you will be a critical contributor to meeting CoventBridge Group's objective: To provide services to our clients that exceed their expectations and contribute to improved healthcare delivery by identifying and eliminating fraud, waste and abuse.
• This position will report directly to the Medical Review Supervisor and will work in our Grove City, OH office. If not local, remotely from a home office.
• Responsibilities
• Reviews information contained in Standard Claims Processing System files (e.g., claims history, provider files) to determine provider billing patterns and to detect potentially fraudulent or abusive billing practices or vulnerabilities in Medicare or Medicaid payment policies
• Utilizes extensive knowledge of medical terminology, ICD-9-CM, ICD-10-CM HCPCS Level II and CPT coding along with analysis and processing of Medicare claims. Utilizes Medicare/Medicaid and Contractor guidelines for coverage determinations
• Coordinates and compiles the written Investigative Summary Report to the PI Investigator upon completion of the records review
• Incorporates leadership and communication skills to work with physicians and other health professionals as well as external regulatory agencies and law enforcement personnel
• Provides training to UPIC staff on medical terminology, reading medical records, and policy interpretation
• Provides expert witness testimony as required
• Completes assignments in a manner that meets or exceeds the quality assurance goal of 98% accuracy
• Maintains chain of custody on all documents and follows all confidentiality and security guidelines
• Performs other duties as assigned by the Medical Review Supervisor that contribute to UPIC goals and objectives and comply with the Program Integrity Manual and Statement of Work guidelines and CMS directives and regulations
• Requirements
• 2 years minimum experience with a state Medicaid agency or Managed Care Organization focused in Medicaid
• 2 years minimum of working knowledge of ICD 10-CM/CPT coding experience
• 4 years minimum experience auditing claims history or provider files to determine if the claim was payable and if any signed of fraud, waste or abuse are noted
• Knowledge of, and the ability to correctly identify, Medicare and Medicaid coverage guidelines
• Advance knowledge of medical terminology and experience in the analysis and processing of Medicare claims, utilization review/ quality assurance procedures, ICD 10-CM and CPT coding, Medicare coverage guidelines and payment methodologies (i.e., Correct Coding Initiative, DRG's, Prospective Payment Systems and Ambulatory Surgical center), NCPCP and other types of prescription drug claims
• Ability to read Medicaid claims, both paper and electronic, and a basic knowledge of Medicaid is required
• Should possess excellent verbal and written communication skills with an ability to write professional summary reports
• Knowledge of and ability to use Microsoft Word, Excel, and Internet applications
• Able to efficiently organize and manage workload and assignments
• Must have and maintain a valid driver' license for the state of residence as on-site audits are part of the role as a nurse reviewer
• Graduate from an accredited school of nursing and have an active license as a Registered Nurse (RN) required
• Nice-to-haves
• Preference given to BSN or higher prepared nurses with recent medical review claims experience in Medicare or Medicaid reviews
• Benefits
• Medical, Dental, Vision plans
• Life, LTD and STD paid by the employer
• 401(k) with company match up to 4%
• Paid Time Off and company paid holidays
• Tuition assistance after 1 year of service

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