Job Description Summary:
The Lead Claims Review Analyst (LCRA) will perform pre and/or post-pay medical review workload for Medicare claims in support of program integrity work for the UPIC Mid-Western Jurisdiction 1 (J1).
Reviews 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
Utilizes extensive knowledge of medical terminology, ICD-10-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
Coordinates and compiles the written Investigative Summary Report upon completion of the records review
At least 2 years utilization/quality assurance review and ICD-10-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
Advanced knowledge of medical terminology and experience in the analysis and processing of Medicare claims, utilization review/quality assurance procedures, ICD-10-CM 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
Ability to read Medicare and Medicaid claims, both paper and electronic, and a basic knowledge of the Medicare and Medicaid claims systems
Graduate from an accredited school of nursing and has an active license as a Registered Nurse (RN)
Certified coding specialist preferred
Working from our prime contractor’s office in Grove City, OH
A work from home position may be considered for the right candidate, if living in the states of Minnesota, Wisconsin, Illinois, Indiana, Michigan, Ohio, Kentucky, Iowa, Missouri, Nebraska and Kansas.
Office Equipment Required: (If approved for work from home.)
Locking cabinet and/or desk for storing documents and electronic media
Broadband internet connection
Phone line (land line or cellular)
May require prolonged periods of sitting at a desk and working on a computer.
Must have and maintain a valid driver's license for the associate’s state of residence.
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 & sect; 1154(b)(1) of the Social Security Act.
All necessary travel expenses, if applicable, are reimbursable via GSA standards.
Why Work Here?Accomplished federal contractor specializing in fighting fraud, waste, and abuse in government entitlement programs.
Small Veteran Owned Business. Family owned and operated.