ANALYTICA is seeking a Medical Record Reviewer/Lead Claims Review Analyst to perform pre and/or postpay medical review workload for Medicare and/or Medicaid claims in support of program integrity work for CMS.
- 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-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.
- Coordinates and compiles the written Investigative Summary Report to the PI Investigator upon completion of the records review.
Education and Experience:
- At least 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 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.
- Graduate from an accredited school of nursing and has an active license as a Registered Nurse (RN).
- 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.
- Certified coding specialist preferred.
About ANALYTICA: Analytica is a leading consulting and information technology solutions provider to public sector organizations supporting health, civilian, and national security missions. Founded in 2009 and headquartered in Washington D.C., the company is an established SBA certified HUBZone and 8(a) small business that has been recognized by Inc. Magazine each of the past three years as one of the 250 fastest-growing companies in the U.S. Analytica specializes in providing software and systems engineering, information management, analytics & visualization, agile project management, and management consulting services. The company is appraised by the Software Engineering Institute (SEI) at CMMI® Maturity Level 3 and is an ISO 9001:2008 certified provider.