Catapult Consultants is currently seeking a Medical Reviewer. The Medical Reviewer (RN) performs pre and/or postpay medical review workload for Medicare and/or Medicaid claims in support of program integrity work for UPIC Mid-Western Jurisdiction.
- 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, HCPCS Level II and CPT coding along with analysis and processing of Medicare and Medicaid claims. Utilizes Medicare, Medicaid and Contractor guidelines for coverage determinations.
- Coordinate and compile the written Investigative Summary Report to the PI Investigator upon completion of the records review.
- Degree from an accredited school of nursing and an active license as a Registered Nurse (RN) required.
- Minimum of 2 years utilization/quality assurance review and ICD-9-CM/CPT coding experience.
- Minimum of 5 years clinical experience or equivalent experience in the Medical Review field.
- Experience in coding and abstracting, working knowledge of Diagnosis Related Groups (DRGs), Prospective Payment Systems, and Medicare and/or Medicaid coverage guidelines is required.
- Advanced knowledge of medical terminology and experience in the analysis and processing of Medicare claims, utilization review/quality assurance procedures, ICD-9-CM/10 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.
- Ability to read Medicare and Medicaid claims, both paper and electronic, and a basic knowledge of the Medicare and Medicaid claims systems is required.
- Certified coding specialist preferred.
- Recent Medical Review experience in fraud, waste and abuse at ZPIC or UPIC level preferred.
- 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 § 1154(b)(1) of the Social Security Act.
- Must have and maintain a valid driver’s license for the associate’s state of residence.
- While performing the duties of this job the employee is regularly required to sit and use hands to finger, handle, or feel while typing at a computer keyboard.
- The employee is occasionally required to stand, walk, reach, or lift objects up to 10 pounds.
- The employee is frequently required to talk or hear. The vision requirements include: close vision.
Catapult Consultants is an Equal Opportunity Employer. We believe that every employee has the right to work in a dignified work environment free from all forms of discrimination and harassment. It’s our policy to recruit, employ, retain, compensate, train, promote, discipline, terminate and otherwise treat all employees and job applicants based solely on qualifications, performance, and competence. This policy reflects our belief that providing equal opportunities for all employees is a both our legal and moral responsibility, and good management practice.
All employees and applicants are treated without regard to age, sex, color, religion, race, national origin, citizenship, veteran status, current or future military status, sexual orientation, gender identification, marital or familial status, disability or any other status protected by law.
The above statements are intended to describe the general nature and level of work being performed by people assigned to this classification. They are not to be construed as an exhaustive list of all responsibilities, duties, and skills required of personnel so classified. All personnel may be required to perform duties outside of their normal responsibilities from time to time, as needed.