Seeking a full-time, remote, Nurse RN with coding experience for Medical Reviewer opening. Will perform pre and/or post pay medical review workload for Medicare claims in support of Program Integrity work for CMS UPIC Task Order.
Specific Tasks:
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, ICD-10-CM, HCPCS Level II and CPT coding along with analysis and processing of Medicare and Medicaid claims. Utilizes Medicare, Medicaid and Contractor guidelines for coverage determinations.
Coordinates and compiles the written Investigative Summary Report to program integrity team upon completion of the records review.
Experience:
At least 2 years minimum experience working on ZPIC, UPIC, RAC, MAC or other government programs
At least 2 years minimum working knowledge of ICS10-CM/CPT coding experience.
Minimum of 4 years clinical experience or equivalent experience in the Medical Review field.
At least 4 years minimum experience/working knowledge of Diagnosis Related Groups (DRGs), Prospective Payment Systems, or Medicare Part B claims and Medicare coverage guidelines
Advanced knowledge of medical terminology and experience in the analysis and processing of Medicare claims, utilization review/quality assurance procedures, ICD-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
Ability to read Medicare and Medicaid claims, both paper and electronic, and a basic knowledge of the Medicare and Medicaid claims systems is required.
Education:
Graduate from an accredited school of nursing and has an active license as a Registered Nurse
Must have no adverse actions pending or taken against him/her by any State or Federal licensing board or program; and must have no conflict of interest (COI) as defined in § 1154(b)(1) of the Social Security Act.
Must have and maintain a valid driver’s license for the associate’s state of residence.
Location:
Remote from employee home office. Equipment will be supplied by employer.
Required licenses or certifications:
Graduate from an accredited school of nursing and have an active license as a Registered Nurse (RN) required
Preference given to BSN or higher prepared nurses with recent medical review claims experience in Medicare or Medicaid reviews
Certified coding background preferred
