[Hiring] Medical Reviewer III @CoventBridge Group

This description is a summary of our understanding of the job description. Click on 'Apply' button to find out more. Role Description The Medical Reviewer III (MCP) will be responsible for conducting clinical reviews of medical records for the Medicaid Managed Care Project (MCP). Applies Medicaid guidelines in making clinical determinations as to the appropriateness of payment coverage. • Using knowledge of Medicaid state and federal laws, rules, and regulations, to contribute to the development of review criteria to be approved for use in the review of claims • Review information contained in project plan to ensure claims are paid correctly, documentation supported services as provided, etc. • Utilize extensive knowledge of medical terminology, ICD-10-CM, HCPCS Level II and CPT coding along with analysis and processing of Medicaid claims • Utilize MCP guidelines for coverage determinations, and utilize state specific guidelines and regulations for claim determinations • Coordinate and compile written Investigative Summary Reports in conjunction with PI Investigators upon completion of the records review • Uses leadership and communication skills to collaborate with physicians and other health professionals, as well as external regulatory agencies and law enforcement personnel • Provide expert witness testimony as required • Complete assignments in a manner that meets or exceeds the quality assurance goal of 95% accuracy • Maintains chain of custody on all documents and follows all confidentiality and security guidelines • Perform other duties as assigned by the Medical Review Supervisor that contribute to UPIC goals and objectives, comply with the Program Integrity Manual (PIM), Statement of Work (SOW) guidelines, and CMS directives and regulations Qualifications • Graduated from an accredited school of nursing and has an active license as a Registered Nurse (RN) • At least 4 years’ utilization/quality assurance review and ICD-10-CM/CPT-4 coding experience • At least 4 years’ experience in coding and abstracting; working knowledge of Diagnosis Related Groups (DRGs) is required • Advanced knowledge of medical terminology and experience in the analysis and processing of Medicaid claims, utilization review/quality assurance procedures, ICD-10-CM and CPT-4 coding, Medicaid coverage guidelines, and payment methodologies (i.e., Correct Coding Initiative, DRGs), NCPDP and other types of prescription drug claims is required Requirements • Knowledge of, and the ability to correctly identify Medicaid coverage guidelines • Ability to read a Medicaid claim and basic knowledge of Medicaid claims • Excellent verbal and written communication skills • Knowledge of and ability to use Microsoft Word, Excel, and Internet applications • Ability to efficiently organize and manage workload and assignments 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 Apply tot his job Apply To this Job