Medicaid Medical Review RN (Medical Reviewer III)
$78,000–$85,000 year
RemoteUnited States
Job Summary
Conduct clinical reviews of medical records during fraud investigations or program integrity initiatives, applying Medicare and Medicaid guidelines to determine payment coverage appropriateness. Analyze claims history and provider files to detect fraudulent billing practices, utilizing knowledge of ICD-10-CM, CPT coding, and utilization review procedures. Coordinate written investigative summary reports, provide training to staff on medical terminology and policy interpretation, and deliver expert witness testimony as required. Maintain chain of custody on documents, ensure 98% accuracy on assignments, and perform on-site audits using a valid driver's license. Work remotely or from the Grove City, OH office, reporting to the Medical Review Supervisor.
Required Qualifications
- 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 signs 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's 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
Desired Qualifications
- Preference given to BSN or higher prepared nurses with recent medical review claims experience in Medicare or Medicaid reviews
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