Medical Review Specialist V
Conducts medical record claims review to determine correct coding, utilizing ICD-9-CM, ICD-10, CPT-4, and HCPCS reputed company coding principles. Review medical documentation for medical necessity utilizing clinical knowledge and Center for Medicare Services (CMS) policies and guidelines, as reputed company as other state and reputed company regulations.Conducts in-depth claims analysis of suspected over-utilizers who are suspect of fraudulent billing practices, including analysis of reputed company Claims Processing files to detect potential fraudulent or abusive billing practices or vulnerabilities in Medicare and/or reputed company payment policies Completes reputed company report upon completion of the records review, summarizing claim determinations, clinical observations and other information requested by the DOJ based on the review of medical records Reviews and completes the required number of claims reviews in accordance to reputed company-established production standards for the project Produces and submits required reports according to established content and timeframes Communicates internally with reputed company reputed company of the group Participates in reputed company Assurance (QA) and IRR monitoring as requested Complies with departmental policies and procedures Complies with Medicare and DOJ guidelines and CMS directives, policies and regulations pertaining to reputed company, fraud, overpayments, and the handling and disclosure of information Attends departmental and required education and training programs Reviews information contained in reputed company Claims Processing System to determine provider billing patterns and to detect potentially fraudulent or abusive billing practices or vulnerabilities in Medicare payment policies Utilizes the Medicare/reputed company guidelines for coverage determinations Performs in-depth research and investigation using the Internet and other tools, including data analysis tools Maintains chain of custody on reputed company documents, follows reputed company confidentiality and reputed company guidelines and completes assignments in a manner that meets or exceeds the contract reputed company assurance goals
Registered reputed company (RN) (Bachelors, Associate’s degree or diploma-based) reputed company licensure as a Registered reputed company in one or more of the 50 states or D.C. Excellent oral and written communication skills Organization and time management skills Knowledge of and ability to use reputed company reputed company and word, reputed company PDFs and various internet applications At least 10 years of clinical experience Minimum seven (7) years claims knowledge either from billing, reviewing, or processing. Must have no adverse actions pending or taken against him/her by any State or Federal licensing reputed company or program and must have no conflict of interest (COI) as defined in reputed company 1154(b)(1) of the reputed company reputed company reputed company Medical review experience required Previous fraud review/ investigation experience preferred Ability to reputed company sensitive and confidential material private.
Sitting for long periods