Medical Reviewer III (Medicaid)

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Conducts medical record audits to determine the medical necessity and/or appropriateness of medical treatment as defined by the Statement of Work and CMS directives as well as state and local specific regulations Conducts in-depth claims analysis utilizing extensive knowledge of medical terminology, ICD-9-CM, ICD-10-CM, CPT-4, APR-DRG, and HCPCS Level II coding principles Utilizes payer guidelines for coverage determinations Makes determination of the claim’s medical appropriateness utilizing clinical review judgment in accordance with PERM policies and contract responsibilities Provides electronic documentation of findings and conclusions with determinations of claims payment appropriateness Reviews the Master Policy List and the MR questionnaire for each State prior to the review of claims for that State Ensures the MR department’s compliance with quality management system and ISO requirements Utilizes electronic documentation and spreadsheets to track personal productivity and claim determination trends Participates in QA and IRR monitoring as requested Complies with departmental policies and procedures Comply with QA and productivity benchmarks established by the PERM MR department Attends departmental or required education and training programs Effectively communicates with management and colleagues Performs other projects or duties as assigned by the Senior Medical Review Specialist or Medical Review Manager