Medical Reviewer Nurse (RN)
Performs pre and/or postpay medical review workload for Medicare and/or Medicaid claims in support of program integrity work for UPIC Mid-Western Jurisdiction.
· 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, 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 the PI Investigator upon completion of the records review.
· At least 2 years utilization/quality assurance review and ICD-9-CM/CPT coding experience.
· Minimum of 5 years clinical experience or equivalent experience in the Medical Review field.
· Experience in coding and abstracting, working knowledge of Diagnosis Related Groups (DRGs), Prospective Payment Systems, and Medicare and/or Medicaid coverage guidelines is required.
· Advanced knowledge of medical terminology and experience in the analysis and processing of Medicare claims, utilization review/quality assurance procedures, ICD-9-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 is required.
· Ability to read Medicare and Medicaid claims, both paper and electronic, and a basic knowledge of the Medicare and Medicaid claims systems is required.
· Graduate from an accredited school of nursing and has an active license as a Registered Nurse (RN).
· 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.
· Certified coding specialist preferred.
· This is a full-time contract position with benefits.
· Work can be performed at our prime contractor’s facility in Grove City, OH; or within one of the following MW states: Minnesota, Wisconsin, Illinois, Indiana, Michigan, Ohio, Kentucky, Iowa, Missouri, Nebraska, and Kansas. Telework nationwide may be permitted.
· Period of performance is through 12/31/2019, with the possibility of an extension.
· Travel may be required as necessary, with prior approval. All necessary travel expenses are reimbursable via GSA standards
· Equal Opportunity Employer/Veterans/Disabled.
· For more information about CES, please visit www.cesnb.com.