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Medical Reviewer III

CES, LLC Indianapolis ,IN
  • Expired: over a month ago. Applications are no longer accepted.
Job Description

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


Required qualifications/skills:

  • 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)


Preferred qualifications/skills:

  • 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.


Supervisory Responsibilities:

  • None.


Office Equipment Required: (If approved for work from home.)

  • Locking cabinet and/or desk for storing documents and electronic media

  • Cross-cut shredder

  • Broadband internet connection

  • Phone line (land line or cellular)


Physical Requirements:

  • 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.

Company Description
Accomplished federal contractor specializing in fighting fraud, waste, and abuse in government entitlement programs.


Why Work Here?

Small Veteran Owned Business. Family owned and operated.

Accomplished federal contractor specializing in fighting fraud, waste, and abuse in government entitlement programs.


Indianapolis, IN