Medical Reviewer III (Medicare/DRG)

Overview

Our talent team at Get A Job.ai is representing a confidential healthcare technology organization seeking a Medical Reviewer III specializing in Medicare and DRG claims review. This casual position offers an opportunity to perform comprehensive medical record analysis and payment determinations in support of federal healthcare programs. You'll apply your clinical nursing expertise and claims knowledge to ensure accurate Medicare reimbursement decisions while working remotely across the United States.

Responsibilities

• Perform comprehensive medical record and claims review to make payment determinations based on insurance coverage, coding principles, and utilization guidelines for Medicare DRG claims
• Conduct first-level medical review in determination of claims payment decisions
• Complete in-depth claims analysis utilizing ICD-10-CM, CPT-4, and HCPCS Level II coding standards
• Utilize electronic health information imaging systems and input medical review decisions via electronic database modules
• Access internet and intranet sources for policy verification and ensure adherence to federal and local Medicare regulations
• Work with Microsoft Office suite and other software templates for claims review documentation
• Apply clinical judgment based on nursing experience when making medical necessity determinations
• Meet established quality and production standards while ensuring compliance with quality management system requirements
• Complete additional projects or duties as assigned by medical review leadership

What We're Looking For

Required Qualifications:

• Active Registered Nurse license obtained through Bachelor's degree, Associate's degree, or Diploma in Nursing
• Current RN licensure in one or more of the 50 states or District of Columbia
• At least four (4) years of claims knowledge from billing, reviewing, or processing of Durable Medical Equipment
• At least three (3) years of clinical experience as a Registered Nurse
• Minimum two (2) years applying federal and local policy in relation to Medicare insurance procedures for medical necessity for Physician Office practices, Laboratory, and Ambulance Services
• Ability to maintain confidentiality of sensitive material
• No adverse actions pending or taken by any State or Federal licensing board and no conflicts of interest
• Ability to sit and stand for extended periods

Preferred Experience:

• Background in Physician Office, Hospital, Supplier, or Clinic settings providing DME equipment care/services
• Prior experience as a Medicare Contractor Medical Review Nurse or in Commercial Insurance review
• Bilingual (Spanish) – fluency in reading and understanding Spanish medical records is a plus

How We Work With You

When you apply through Get A Job.ai, one of our experienced recruiters will review your qualifications and conduct an initial screening. If your background aligns with our client's needs, we will submit your profile for consideration. Please note that all applications must go through Get A Job.ai—do not contact the client directly. Our team will guide you through each step of the process and serve as your advocate throughout.

Pay

Pay information will be discussed during the screening process with our recruiting team.

Equal Employment Opportunity: Get A Job.ai is committed to providing equal employment opportunities to all applicants regardless of race, color, religion, sex, national origin, age, disability, veteran status, or any other protected characteristic under applicable law.