Rn with varied experience reviewing medicare parts a, b, c, d, including dme claims and supervisory experience supporting medical review manager and project staff.
He/she will also have to have a certification in coding or in the near process of obtaining one.
Billing, coding, and medical record documentation processes in clinical settings; Claims processing, including adjudication, payment, adjustment, demand and recovery Medical review, including determinations, authorizations, peer review, utilization review, and appeals Program integrity activities, including surveillance, step-edits, audits, surveys, pre-payment and post-payment review, investigations, referrals Provider management, including credentialing, performance measurement, education, referral Payment policy and regulation, including demonstrations, models, carve-outs, legislation
Multiple payers – medicare, medicaid, commercial Multiple payer-types, including fee-for-service (ffs), managed care, capitated
Expertise in medical terminology and all healthcare coding (e.g., icd-10, cpt, hcpcs) Strong knowledge of health care benefit structure and claim processing systems Experience researching and interpreting payer medical (coverage) policies (e.g., lcds, ncds, private carrier medical policies) and common industry claim edits (e.g., ncci) Ability to communicate technical and non-technical language to technical and non-technical audiences Ability to prioritize multiple tasks to meet established deadlines and satisfy internal and external customer demands Proficient in microsoft products, tableau Bachelor’s degree in relevant healthcare or related discipline Registered nurse (rn) and/or bachelor of science in nursing (bsn) or similar caliber clinical training Certified professional coder (cpc) through the american academy of professional coders (aapc) or certified coding specialist (ccs) through the american health information management association (ahim5
Education and/or credentials
Bachelor’s degree in relevant healthcare or related discipline Registered nurse (rn) and/or bachelor of science in nursing (bsn)