Medical Reviewer III, Medicare/DME

Job Description: • Perform comprehensive medical record and claims review to make payment determinations based on Insurance coverage, coding, and utilization of services and practice guidelines for Medicare DME. • Performs first and second level of Medical Review in determination of claims payment review. • Conducts in-depth claims analysis utilizing ICD-10-CM, CPT-4, and HCPCS Level II coding principles. • 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 review of Medicare DME claims. • 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 Lead Specialist. 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 of Durable Medical Equipment. • At least three (4) years clinical experience as a Registered Nurse. • Minimum two (2) 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). Benefits: • Flexible working arrangements • Professional development opportunities Apply tot his job