Summary Description

Primarily responsible for conducting clinical reviews of medical records during the course of fraud investigations or other program integrity initiatives such as requests for information or in support of proactive data analysis efforts. Applies Medicare guidelines in making clinical determinations as to the appropriateness of payment coverage.

Review information contained in Standard Claims Processing System files (e.g., claims history, provider files) to determine provider billing patterns and to detect potentially fraudulent or abusive billing practices or vulnerabilities in Medicare payment policies.

Utilize extensive knowledge of medical terminology, ICD-9-CM and ICD-10-CM, HCPCS Level II and CPT coding along with analysis and processing of Medicare claims. Utilize Medicare and Contractor guidelines for coverage determinations.

Coordinate and compile written Investigative Summary Reports in conjunction with PI Investigators upon completion of the records review.

Uses leadership and communication skill to work with physicians and other health professionals as well as external regulatory agencies and law enforcement personnel.

Provide training to UPIC staff on medical terminology, reading medical records, and policy interpretation.

Provide expert witness testimony as required.

Complete assignments in a manner that meets or exceeds the quality assurance goal of 98% accuracy.

Maintain chain of custody on all documents and follows all confidentiality and security guidelines.

Perform other duties as assigned by the Medical Review Supervisor that contribute to UPIC goals and objectives and comply with the Program Integrity Manual and Statement of Work guidelines and CMS directives and regulations.

Qualifications

Education (general level if required) or specific courses

Graduate from an accredited school of nursing and has an active license as a Registered Nurse (RN). Must have and maintain a valid driver’s license for the associate’s state of residence.

Skills, Knowledge

Abilities (SKA)

Knowledge of, and the ability to correctly identify, Medicare coverage guidelines

Should possess excellent oral and written communication skills

Knowledge of and ability to use Microsoft Word, Excel and Internet applications

Able to efficiently organize and manage workload and assignments.

§ Experience (If needed, describe kind & amount)

Ø At least 4 years’ utilization/quality assurance review and ICD-9/10-CM/CPT-4 coding experience.

Ø At least 4 years’ experience in coding and abstracting, working knowledge of Diagnosis Related Groups (DRGs), Prospective Payment Systems, and Medicare coverage guidelines is required.

Ø Advanced knowledge of medical terminology and experience in the analysis and processing of Medicare claims, utilization review/quality assurance procedures, ICD-9/10-CM and CPT-4 coding, Medicare coverage guidelines, and payment methodologies (i.e., Correct Coding Initiative, DRGs, Prospective Payment Systems, and Ambulatory Surgical Center), NCPDP and other types of prescription drug claims is required.

Ø Ability to read Medicare claims, both paper and electronic, and a basic knowledge of the Medicare claims systems is required

Job Type: Full-time