Medicaid Medical Review RN (Medical Reviewer III)

CoventBridge Group is the global leader in full-service investigations providing Surveillance, SIU and Compliance, Claims Investigation, Counter-Fraud Programs, Desktop Investigations, Social Media, Record Retrieval, Canvasses and Vendor Management programs. The company provides top tier data privacy and security practices, deploys robust case management technology customized to clients’ needs and delivers worldwide coverage via its 1000 employees and affiliates worldwide.

The Medicaid Medical Review RN (Medical Reviewer III) will primarily be 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. In addition, this position applies Medicare and Medicaid guidelines in making clinical determinations as to the appropriateness of payment coverage. In assuming this position, you will be a critical contributor to meeting CoventBridge Group's objective: To provide services to our clients that exceed their expectations and contribute to improved healthcare delivery by identifying and eliminating fraud, waste and abuse. This position will report directly to the Medical Review Supervisor and will work in our Grove City, OH office. If not local, remotely from a home office.

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 or Medicaid 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 claims. Utilizes Medicare/Medicaid 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 UPIC 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 UPIC goals and objectives and comply with the Program Integrity Manual and Statement of Work guidelines and CMS directives and regulations