compensation: Based on experience employment type: contract
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Primarily 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. Applies Medicare guidelines in making clinical determinations as to the appropriateness of payment coverage.
Skills, Knowledge Abilities (SKA)
Experienced working with Microsoft Office Suite
Knowledge of, and the ability to correctly identify, Medicare coverage guidelines.
Should possess excellent oral and written communication skills.
Knowledge of and ability to use Microsoft Word, Excel and Internet applications.
Able to efficiently organize and manage workload and assignments.
Recent Medicare Medical Review minimum 1 year of experience doing Home Health, Hospice or SNF review
Minimum of 5 years' experience as a Clinician
At least 2 years utilization/quality assurance review and ICD-9/10-CM/CPT-4 coding experience.
Experience in coding and abstracting, working knowledge of Diagnosis Related Groups (DRGs), Prospective Payment Systems, and Medicare coverage guidelines is required.
Advanced knowledge of medical terminology and experience in the analysis and processing of Medicare claims, utilization review/quality assurance procedures, ICD-9/10-CM and CPT-4 coding, Medicare coverage guidelines, and payment methodologies (i.e., Correct Coding Initiative, DRGs, Prospective Payment Systems, and Ambulatory Surgical Center), NCPDP and other types of prescription drug claims is required.
Ability to read Medicare claims, both paper and electronic, and a basic knowledge of the Medicare claims systems is required.
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 payment policies.
Utilizes extensive knowledge of medical terminology, ICD-9-CM, HCPCS Level II and CPT coding along with analysis and processing of Medicare claims. Utilizes Medicare 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 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 goals and objectives and comply with the Program Integrity Manual and Statement of Work guidelines and CMS directives and regulations.
Education (general level if required) or specific courses
Graduate from an accredited school of nursing and has an active license as a Registered Nurse (RN) Must have and maintain a valid driver's license for the associate's state of residence
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