Medical Review Nurse III

Healthcare & Medicine Other Remote Permanent / Full Time Job Description Summary: The Medical Reviewer will utilize Medicare and/or Medicaid rules, regulations, and guidelines in reviewing medical records documentation to determine if a claim meets these requirements. Primarily 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. Applies Medicare guidelines in making clinical determinations as to the appropriateness of payment coverage. The Medical Reviewer coordinates and compiles the written Investigative Summary Report to the Program Integrity Investigator upon completion of the records review within timelines set by CMS.

Review 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 Utilize extensive knowledge of medical terminology, ICD-9-CM and ICD-10-CM, HCPCS Level II and CPT coding along with analysis and processing of Medicare claims. Utilize Medicare and Contractor guidelines for coverage determination Coordinate and compile written Investigative Summary Reports in conjunction with PI Investigators upon completion of the records review Uses leadership and communication skill to work with physicians and other health professionals as well as external regulatory agencies and law enforcement personnel Provide training to staff on medical terminology, reading medical records, and policy interpretation Provide expert witness testimony as required Complete assignments in a manner that meets or exceeds the quality assurance goal of 98% accuracy Maintain 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 goals and objectives and comply with the Program Integrity Manual and Statement of Work guidelines and CMS directives and regulations