HMS makes the healthcare system work better for everyone. We fight fraud, waste, and abuse so people have access to healthcare—now and in the future. Using innovative technology and powerful data analytics, we help government and commercial payers reduce costs, increase quality, and achieve regulatory compliance. We also help consumers take a more active role in their own health. Each year, we save our clients billions of dollars while helping people live healthier lives. At HMS, you will develop new skills and build your career in a dynamic industry while making a difference in the lives of others.
We are seeking a talented individual for a Medical Review Nurse who is responsible for providing medical record review and assists with preparation of writing of audit reports and documents.
- Perform a clinical review of medical records and/or other documentation to determine that services billed to and paid by the Medicaid agency are supported. This includes review for correct coding and medical necessity.
- Complete medical review form, accurately documenting findings, and provide policy/regulatory support for determination.
- Conduct research on relevant State specific billing/reimbursement regulations.
- Integrate knowledge of Medicaid/Medicare claims and reimbursement requirements to make accurate claim determination.
- Use knowledge of fraud, waste and abuse definitions to identify and participate in fraud referral when indicated.
- Provide support to internal staff, subcontractors and providers with respect to Medicaid related issues.
- Conduct claim research using the appropriate systems.
- Attend on-site visits to retrieve medical records and conduct provider entrance and exit conference.
- Participate in and contribute to the quality management system.
- Meet project timelines and deliverables.
- Work with Project Team to prepare and write audit documents.
- Serve as Project Lead for selected audits as required
- Warehousing and memorializing documents.
- Performs other functions as assigned
Knowledge, Skills and Abilities:
- Knowledge and adherence to HIPAA Privacy and Security Rules and CMS security requirements.
- Familiarity with coding principles to include ICD-9, CPT, HCPCS, DRG and RBRVS. CPC is preferred.
- Familiarity and thorough understanding of billing forms, RA’s, EOB’s and provider billing statements.
- Familiarity with Medicaid rules and regulations is required.
- Ability to maintain high quality work while meeting deadlines.
- Excellent writing skills used to produce work free from typographical or spelling errors.
- Working knowledge of technology including Microsoft Office, Internet and e-mail.
- Ability to read, comprehend, review and analyze information
- Ability to work well in a high stressed, fast paced, constantly evolving environment; Requires performing a variety of duties, often changing from one task to another
- Required to perform tasks with frequent interruptions or distractions in a moderately noisy office environment
- Frequently required to remember information and details to successfully perform the job
- Must be able to organize workflow, prioritize tasks, meet deadlines and be flexible when working in a team
- Is frequently required to work from the assigned office location and may be occasionally allowed to attend meetings virtually
- Frequently required to analyze information and data; arrive at a conclusion; to study the factors of a situation or problem in order to determine the solution or outcome;
- Frequently perform mathematical calculations
Work Conditions and Physical Demands:
- Primarily sedentary work in a general office environment
- Ability to communicate and exchange information
- Ability to comprehend and interpret documents and data
- Requires occasional standing, walking, lifting, and moving objects (up to 10 lbs.)
- Requires manual dexterity to use computer, telephone and peripherals
- May be required to work extended hours for special business needs
- May be required to travel at least 35% of time based on business needs
- Associate’s or Bachelor’s degree required.
- Registered Nurse with current license is required.
- CPC Preferred
- Not currently sanctioned or excluded from any program operated by Federal or State Agencies including Medicare and Medicaid.
Minimum Related Work Experience:
- 3+ years’ experience with clinical medical record auditing.
- Minimum three years’ experience as a professional health care provider.
- Clinical work experience is preferred.
Nothing in this job description restricts management’s right to assign or reassign duties and responsibilities to this job at any time.
EOE including disability/veteran
Job Type: Full-time
Pay: $0.00 per hour
- 401(k) Matching
- Dental Insurance
- Disability Insurance
- Employee Assistance Program
- Employee Discount
- Flexible Spending Account
- Health Insurance
- Life Insurance
- Paid Time Off
- Parental Leave
- Professional Development Assistance
- Referral Program
- Tuition Reimbursement
- Vision Insurance
- 8 Hour Shift
- Day shift
- Monday to Friday
- Medicaid: 1 year (Required)
- Registered Nursing (Required)
Company's Facebook page: