Lead Medical Review Specialist - Part B

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As a Lead Medical Review Specialist V (Medical Reviewer V), you will perform management duties including direction and research involving Medicare comprehensive medical record and claims review to make payment determinations for Medicare PART B.  These claim specialties include Physician Offices, Ambulances, Physician Professional Services, Laboratory, and others. Perform management projects and duties as assigned as the Lead Medical Review Specialist.  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. 

Highlights of Responsibilities:

• Perform management level review, direction and research on comprehensive medical record and claims review to make payment determinations based on Insurance coverage, coding, and utilization of services and practice guidelines for Medicare B Physician Office and Professional Services, Ambulance Services, Laboratory, and others.
• Serves as the immediate manager for resources of the medical review specialists on your team involving coverage, coding, and medical necessity issues
• Performs the third level of Medical Review in determination of claims payment review when the first and second level medical review determinations are in opposition
• Provides development and training to integral staff and subcontractors for special studies as well as regular project claims review
• Conducts in-depth claims analysis utilizing ICD-10-CM, CPT-4, and HCPCS Level II coding principles as part of the management team for the customer as well as the Medical Review Manager and Medical Directors
• Utilize electronic health information imaging and input medical review decisions by electronic database module.
• Utilize internet and intranet sources for policy verification.
• Utilize Microsoft Office suite and other software templates as associated source input for claims review.
• Make clinical judgment decisions based on clinical experience when applicable.
• Responsible for the surveillance of medical review specialist’s production and quality review of Medicare Part B claims.
• Supervising the analysis of provider and service specific claims to identify error.
• Meeting quality and production standards.  
• Ensuring departmental compliance with quality managements system and ISO requirements.
• Completes other projects or duties as assigned by the Medical Review Manager

Requirements: 

• Must be a Registered Nurse obtained by either a Bachelor's degree – OR - Associate's degree – OR - Diploma in Nursing.   At least four (4) years claims knowledge either from billing, reviewing, or processing.
• At least ten (10) years clinical experience as a Registered Nurse.
• At least four (4) years supervisory experience
• Minimum four (4) years federal and local policy applications in relation to Medicare insurance procedures for medical necessity for Physician Office practices, Laboratory, and Ambulance Services.
• 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).
• Must have and maintain a valid state driver’s license for the state of residence.
• Prior work as a Medicare Contractor Medical Review Nurse or Commercial Insurance Physician Office/Ambulance Services/Laboratory claims reviewer

Preferred Education and Experience: 

• Optional - Bilingual (Spanish) - Fluency in reading and understanding Spanish language especially as it relates to medical records is a plus!

Physical Requirements:

This position requires the ability to perform the below essential functions:

• Sitting for long periods
• Standing for long periods
• Ambulate throughout an office