Medical Review Analyst - Medicare

What you'll do:

The Medical Reviewer requires the individual to conduct medical record reviews and to apply sound clinical judgment to claim payment decisions.

Responsibilities may include additional research on medical claims data and other sources of information to identify problems, review sophisticated data model output, and utilize a variety of tools to detect situations of potential fraud and to support the ongoing fraud investigations and requests for information. The incumbent will use a variety of tools to identify and develop cases for future administrative action, including referral to law enforcement, education, over payment recovery. Will work with external agencies to develop cases and corrective actions as well as respond to requests for data and support.

Roles and Responsibilities:

Ability to present issues of concern, citing regulatory violations, alleging schemes or scams to defraud the Government
Research regulations and cite violations.
Conduct self-directed research to uncover problems in Medicare payments made to institutional and non-institutional providers.
Make claim payment decisions based on clinical knowledge
This position may require the incumbent to appear in court to testify about work findings.
Ability to compose correspondence, reports, and referral summary letters.
Ability to communicate effectively, internally and externally.
Ability to handle confidential material.
Ability to report work activity on a timely basis.
Ability to work independently and as a member of a team to deliver high quality work.
Ability to attend meetings, trainings, and conferences as needed. Overnight travel may be required.
Telework available from contiguous United States.

Qualifications

Basic Qualifications:

Bachelors and 5 years of experience, Masters degree and 3 years of experience, Associates and 7 years of experience
Experience in the medical field as a Registered Nurse or other clinician, and/or experience in review of medical claims for coverage and medical necessity.
Current/Active Nursing or Physical Therapy license in state of residence.
Strong investigative skills
Strong communication and organization skills
Strong PC knowledge and skills
U.S. citizenship required

Desirable Qualifications:

Experience in reviewing claims for technical requirements, performing medical review, and/or developing fraud cases
Knowledge of Medicare requirements, laws, rules and regulations related to payment for services billed
Have a CPC (Certified Professional Coder) certificate.