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
MEDICAL REVIEWER III
Conducts medical record audits to determine the medical necessity and/or appropriateness of medical treatment as defined by the Statement of Work and CMS directives as well as state and local specific regulations Conducts in-depth claims analysis utilizing extensive knowledge of medical terminology, ICD-9-CM, ICD-10-CM, CPT-4, APR-DRG, and HCPCS Level II coding principlesUtilizes payer guidelines for coverage determinationsMakes determination of the claim’s medical appropriateness utilizing clinical review judgment in accordance with PERM policies and contract responsibilitiesProvides electronic documentation of findings and conclusions with determinations of claims payment appropriatenessReviews the Master Policy List and the MR questionnaire for each State prior to the review of claims for that StateEnsures the MR department’s compliance with quality management system and ISO requirementsUtilizes electronic documentation and spreadsheets to track personal productivity and claim determination trendsParticipates in QA and IRR monitoring as requestedComplies with departmental policies and proceduresComply with QA and productivity benchmarks established by the PERM MR departmentAttends departmental or required education and training programsEffectively communicates with management and colleaguesPerforms other projects or duties as assigned by the Senior Medical Review Specialist or Medical Review Manager QualificationsRequirements:
Active RN state licensure 4-9 years experienceAt least four (4) years clinical experience in a medical/surgical setting At least two (2) years of medical record audit experienceFamiliarity with Medicaid and/or CHIP programCritical thinking and analytical skillsHighly developed organization and time management skillsAbility to work in a telecommute team environmentAbility to keep sensitive and confidential material privateMust have no adverse actions pending or taken against him/her by any State or Federal licensing board or program
Preferred Education and Experience:
Active professional coding certification or the ability to obtain certification within eighteen (18) months of employment
Demonstrated knowledge of ICD-9-CM, ICD-10-CM, CPT-4, APR-DRG, and HCPCS Level II coding principlesFamiliarity with CERT, DOJ, ZPIC, UPIC, or PERM claim audits
Physical Requirements:
This position requires the ability to perform the below essential functions:
Sitting for long periods
About Empower AI
It is the policy of Empower AI to provide equal opportunity in recruiting, hiring, training, and promoting individuals in all job categories without regard to race, color, religion, national origin, gender, age, disability, genetic information, veteran status, sexual orientation, gender identity, or any other protected class or category as may be defined by federal, state, or local laws or regulations. In addition, we affirm that all compensation, benefits, company-sponsored training, educational assistance, social, and recreational programs are administered without regard to race, color, religion, national origin, gender, age, disability, genetic information, veteran status, sexual orientation, or gender identity. It is our firm intent to support equal employment opportunity and affirmative action in keeping with applicable federal, state, and local laws and regulations. Empower AI is a VEVRAA Federal Contractor.
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