The Registered Nurse will perform medical reviews of complex claims, pre-authorization requests, appeals, and fraud referrals to determine medical necessity. They will also provide clear rationales for payment determinations and educate internal and external teams on coverage guidelines.
The Medical Reviewer will conduct comprehensive reviews of home health pre-claim review packages to ensure compliance with Medicare coverage, coding, and payment criteria. They are responsible for documenting clinical rationales and maintaining a 98% accuracy standard while meeting strict turnaround times.
The Senior Medical Reviewer supervises a team of RNs to ensure accurate Medicare medical review operations and timely case turnaround. They are responsible for monitoring workload distribution, ensuring compliance with security requirements, and escalating complex provider or integrity issues.
The QA Coordinator supports quality coordination activities, including case assignment and complex case reviews, while serving as the point of contact for inter-rater reliability (IRR) activities. They monitor reviewer performance to ensure consistent application of Medicare requirements and implement corrective actions as needed.
Perform complex medical reviews of Medicare claims for Inpatient Rehabilitation Facility services. Conduct pre-claim review determinations and communicate findings directly to providers.
The recruiter will consult with leadership to identify and evaluate qualified clinical and technical talent for federal contracts and internal growth. Responsibilities include sourcing candidates, managing the interview process, and coordinating with stakeholders to support proposal-driven hiring efforts.
The Project Controller will lead federal project delivery for CMS, HHS, and DoD clients by managing audit, compliance, and performance oversight engagements. They will serve as the primary interface with government stakeholders, maintaining project plans and reporting on progress.
The Project Coordinator will manage day-to-day project activities, schedules, and deliverable timelines across a portfolio of government contracts. They are responsible for maintaining project documentation, facilitating communication between stakeholders, and supporting compliance reporting and proposal development.
The Redetermination Examiner conducts Medicare redetermination reviews and processes appeals in accordance with CMS guidelines. They are responsible for identifying claims processing deficiencies, maintaining accurate documentation, and providing educational referrals to ensure compliant outcomes.
The Medical Reviewer will evaluate complex claims, pre-authorization requests, and appeals to ensure medical necessity and accurate reimbursement. They will also provide clinical rationales for coverage determinations and support quality control initiatives.
The Appeals Support Specialist is responsible for managing and prioritizing workloads while accurately recording and indexing documentation in the OnBase system. They also coordinate with external stakeholders to order necessary documentation and communicate process trends to management.
The Appeals Support Specialist is responsible for managing and prioritizing workloads while accurately recording and indexing documentation in OnBase. They will also communicate with management regarding process trends and improvements.
The Redetermination Examiner conducts reviews of Medicare claims and responds to appeals in accordance with CMS regulations. They are responsible for identifying processing deficiencies, maintaining accurate documentation, and providing educational support to ensure compliant claim outcomes.
The Provider Enrollment Specialist is responsible for reviewing, researching, and processing medical provider enrollment applications to ensure accuracy and compliance. They also manage provider data in internal databases and communicate with various stakeholders to resolve discrepancies.
The role involves reviewing and responding to Medicare redetermination requests by analyzing medical documentation, coding, and policy guidelines. You will also collaborate with medical staff to determine claim outcomes and ensure accurate financial liability and decision letters.
Conduct pre- and post-payment medical reviews to ensure compliance with clinical criteria and guidelines. Assess medical necessity and reimbursement eligibility for complex claims, appeals, and fraud referrals.
The physician will conduct independent medical case reviews to assess quality of care and adherence to standards. They will also provide expert medical opinions and identify opportunities for improvement.
