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Job Details Job Title: Medical Review Specialist V
Job ID: 2025-8376
Locations: US-Remote | US-VA-Henrico
Category: Administration / Clerical
Type: Casual
Responsibilities As a Medical Review Specialist V (Medical Reviewer V), you will review and analyze Medicare claims sampled by the Department of Justice, using associated medical records, to make payment determinations based on coverage, coding and utilization of services and practice guidelines.
Conducts medical record claims review to determine correct coding, utilizing ICD-9-CM, ICD-10, CPT-4, and HCPCS Level II coding principles. Review medical documentation for medical necessity utilizing clinical knowledge and CMS policies and guidelines, as well as other state and board regulations.
Conducts in-depth claims analysis of suspected over-utilizers who are suspect of fraudulent billing practices, including analysis of Standard Claims Processing files to detect potential fraudulent or abusive billing practices or vulnerabilities in Medicare and/or Medicaid payment policies
Completes summary report upon completion of the records review, summarizing claim determinations, clinical observations and other information requested by the DOJ based on the review of medical records
Reviews and completes the required number of claims reviews in accordance to pre-established production standards for the project
Produces and submits required reports according to established content and timeframes
Communicates internally with all levels of the group
Participates in Quality Assurance (QA) and IRR monitoring as requested
Complies with departmental policies and procedures
Complies with Medicare and DOJ guidelines and CMS directives, policies and regulations pertaining to integrity, fraud, overpayments, and the handling and disclosure of information
Attends departmental and required education and training programs; reviews information contained in Standard Claims Processing System to determine provider billing patterns and to detect potentially fraudulent or abusive billing practices or vulnerabilities in Medicare payment policies
Utilizes the Medicare/Medicaid guidelines for coverage determinations
Performs in-depth research and investigation using the Internet and other tools, including data analysis tools
Maintains chain of custody on all documents, follows all confidentiality and security guidelines and completes assignments in a manner that meets or exceeds the contract quality assurance goals
Qualifications Registered Nurse (RN) (Bachelors, Associate's degree or diploma-based)
Current licensure as a Registered Nurse in one or more of the 50 states or D.C.
Excellent oral and written communication skills
Organization and time management skills
Knowledge of and ability to use Microsoft Excel and Word, Adobe PDFs and various internet applications
At least 10 years of clinical experience
Minimum seven (7) years claims knowledge either from billing, reviewing, or processing
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) as defined in Section 1154(b)(1) of the Social Security Act
Medical review experience required
Previous fraud review/ investigation experience preferred
Ability to keep sensitive and confidential material private
Physical Requirements This position requires the ability to perform the below essential functions: Sitting for long periods.
About Empower AI All hiring and promotion decisions at Empower AI are based on merit to bring the best talent available to contribute to our firm's overall success. It is the policy of Empower AI not to discriminate against any applicant for employment, or employee because of age, color, sex, disability, national origin, race, religion, or veteran status. Empower AI is a VEVRAA Federal Contractor.