Empower AI: As a Medical Review Specialist III (Medical Reviewer III) for Empower AI company, you will perform 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 projects or duties as assigned as a 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. In assuming this position, you will be a critical contributor to meeting Empower AI's mission: To deliver innovative, cost-effective solutions and services that enable our customers to rapidly adapt to dynamic environments.

Highlights of Responsibilities:

• 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 B Physician Office and Professional Services, Ambulance Services, Laboratory, and others
• 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 Part B 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 two (2) years claims knowledge either from billing, reviewing, or processing in an office/outpatient setting.
• At least four (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).
• Must have and maintain a valid state driver’s license for the state of residence.

Preferred Education and Experience:

• Physician Office, Professional Services RN clinical manager and/or administrative nursing experience
• Prior work as a Medicare Contractor Medical Review Nurse or Commercial Insurance Physician Office/Ambulance Services/Laboratory claims reviewer
• 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
• Ambulate between several buildings
• Stoop, kneel, crouch, or crawl as required