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WCC/Lifecare
MN, United States
23 days ago
WCC/Lifecare
Minnesota, United States
23 days ago

Description

Seeking a full-time, remote, Nurse RN with coding experience for Medical Reviewer opening.  Will  perform pre and/or post pay medical review workload for Medicare claims in support of program integrity work for UPIC Mid-Western Jurisdiction 1 (J1).

Specific Tasks:

  • 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 to the PI Investigator upon completion of the records review.

Experience:

  • 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 is required.
  • 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 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.

Education:

  • 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.

Location:

Remote work from home.  Preference given to candidates residing in Minnesota, Wisconsin, Illinois, Indiana, Michigan, Ohio, Kentucky, Iowa, Missouri, Nebraska or Kansas.

Required licenses or certifications:

  • Registered Nurse (RN)
  • Driver's License
  • CPC Certification


Requirements

Education:

  • 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.

    Required licenses or certifications:

    • Registered Nurse (RN)
    • Driver's License
    • CPC Certification

Job Information

  • Job ID: 58467528
  • Location:
    Minnesota, United States
    Wisconsin, United States
    Illinois, United States
    Indiana, United States
    Michigan, United States
    Ohio, United States
    Kentucky, United States
    Iowa, United States
    Missouri, United States
    Nebraska, United States
    Kansas, United States
  • Position Title: NURSE RN/CODER for MEDICAL REVIEWER POSITION
  • Company Name: WCC/Lifecare
  • Job Function: Government
  • Job Type: Contract
  • Job Duration: Indefinite
  • Min Education: BA/BS/Undergraduate
  • Min Experience: 3-5 Years
  • Required Travel: 10-25%
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