Medical Reviewer V

Overview

Empower AI is AI for government. Empower AI gives federal agency leaders the tools to elevate the potential of their workforce with a direct path for meaningful transformation. Headquartered in Reston, Va., Empower AI leverages three decades of experience solving complex challenges in Health, Defense, and Civilian missions. Our proven Empower AI Platform® provides a practical, sustainable path for clients to achieve transformation that is true to who they are, what they do, how they work, with the resources they have. The result is a government workforce that is exponentially more creative and productive. For more information, visit www.Empower.ai.

Empower AI is proud to be recognized as a 2024 Military Friendly Employer by Viqtory, the publisher of G.I. Jobs. This designation reflects the company’s commitment to hiring and supporting active-duty and veteran employees.

Responsibilities

Empower AI, Inc.: As a Technical Lead Medical Review Specialist (Medical Reviewer V) for Empower AI, Inc., you will provide operational support to the Medical Review Manager and the Medical Review Staff in managing production related to claims determinations and review.  You will serve as a critical component in meeting our mission of providing excellent services to our clients. Your experience ensures an exciting and rewarding opportunity to be at the forefront of activities related to implementing healthcare reform on a national level. In assuming this position, you will be a critical contributor to meeting Empower AI, Inc.'s mission: To deliver innovative, cost-effective solutions and services that enable our customers to rapidly adapt to dynamic environments.

HIGHLIGHTS OF RESPONSIBILITIES:

• Reviews and analyzes sampled Medicare claims using associated medical records, to make payment determinations based on coverage, coding, utilization of services and practice guidelines
• Makes medical necessity determinations utilizing clinical review judgment in accordance with the CERT Program policies and contract responsibilities
• Serves as a resource for medical review specialists involving coverage, coding, and medical necessity issues
• Performs third level of Medical Review in determination of claims payment review when the first and second level medical review determinations are in opposition
• Can perform first or second level medical review as needed
• Conducts in-depth claims analysis utilizing ICD-9-CM, ICD-10-CM, CPT-4, and HCPCS Level II coding principles
• Applies the interpretation of ANSI Reason Codes, Revenue Codes, timely MAC Edits and Audit codes and other Medicare billing formats in determination of appropriate billing submissions and reimbursement
• Conducts medical record audits to determine the medical necessity and/or appropriateness of medical treatment using CMS and other national guidelines, as well as local medical review policies
• Provides research and updates to specialty claims review and review team needs
• Provides electronic documentation of findings and conclusions with determinations of claims payment appropriateness in review tool fields
• Reviews and completes referred level claim reviews in accordance to production standards for special studies as well as regular project claims for end of reporting requirements
• Assists with training to integral staff for special studies as well as regular project claims review
• Assists as needed for QC Panel reviews
• Prepares review for  IRR Panel as needed
• Attends Medical Review Lead meetings when necessary and invited
• Assists with questions from medical records or customer service with regard to specific claim type experience
• Complies with Program Integrity Manual (PIM) and Statement of Work (SOW) guidelines and CMS directives and regulations pertaining to integrity, fraud, overpayments, and the handling and disclosure of information
• Complies with departmental policies and procedures.
• Communicates internally with all levels of the CERT Program
• Attends departmental or required education and training programs
• Completes other projects or duties as assigned by the Medical Review Manager

Qualifications

REQUIREMENTS: 

• Bachelor's degree – OR - Associate's degree – OR - Diploma in Nursing.   At least three (3) years claims knowledge either from billing, reviewing, or processing.
• At least three (3) years clinical experience as a Registered Nurse.
• Minimum ten (10) years federal and local policy applications in relation to insurance procedures for medical necessity for skilled nursing facility and Part A claim reimbursements.
• Current licensure as a Registered Nurse in one or more of the 50 states or D.C.
• Ability to keep sensitive and confidential material private.
• 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).

PREFERRED EDUCATION AND EXPERIENCE: 

• Skilled nursing claims review experience and Part A claim reimbursements
• Prior work as a Medicare Contractor Medical Review Nurse
• Optional - Bilingual (Spanish) - Fluency in reading and understanding Spanish language especially as it relates to medical records is a plus!

About Empower AI

All hiring and promotion decisions at Empower AI are based on merit to bring the best talent available to contribute to our firm’s overall success. It is the policy of Empower AI not to discriminate against any applicant for employment, or employee because of age, color, sex, disability, national origin, race, religion, or veteran status. Empower AI is a VEVRAA Federal Contractor.