Medical Review Specialist III (DRG Claims)

Empower AI is AI for government. Empower AI gives federal agency leaders the tools to elevate the potential of their workforce with a direct path for meaningful transformation. Headquartered in Reston, Va., Empower AI leverages three decades of experience solving complex challenges in Health, Defense, and Civilian missions. Our proven Empower AI Platform® provides a practical, sustainable path for clients to achieve transformation that is true to who they are, what they do, how they work, with the resources they have. The result is a government workforce that is exponentially more creative and productive. For more information, visit www.Empower.ai.

Empower AI is proud to be recognized as a 2022 Military Friendly Employer by Viqtory, the publisher of G.I. Jobs. This designation reflects the company’s commitment to hiring and supporting active-duty and veteran employees.

Empower AI: As a Medical Review Specialist III (Medical Reviewer III) for Empower AI Company, you will perform Medicare comprehensive medical record and claims review to make payment determinations for Medicare DRG Inpatient Acute Hospital admissions. Perform projects or duties as assigned by the Lead Medical Review Specialist. You will serve as a critical component in meeting our mission of providing excellent services to our clients. Your experience ensures an exciting and rewarding opportunity to be at the forefront of activities related to implementing healthcare reform on a national level. In assuming this position, you will be a critical contributor to meeting Empower AI's mission: To deliver innovative, cost-effective solutions and services that enable our customers to rapidly adapt to dynamic environments.

 HIGHLIGHTS OF RESPONSIBILITIES:

• Perform comprehensive medical record and claims review to make payment determinations based on Insurance coverage, coding, and utilization of services and practice guidelines for Inpatient Acute Hospital admissions (DRG reimbursed).
• Utilize electronic health information imaging and inputs medical review decisions by electronic database module.
• Utilize internet and intranet sources for policy verification.
• Utilize Microsoft Office suite and other software templates as associated source input for claims review.
• Make clinical judgment decisions based on clinical experience when applicable.
• Responsible for review of Medicare DRG claims.
• Supervising the analysis of provider and service specific claims to identify error.
• Meeting quality and production standards.  
• Ensuring departmental compliance with quality managements system and ISO requirements.

REQUIREMENTS: 

• Bachelor's degree – OR - Associate's degree – OR - Diploma in Nursing.   At least four (4) years claims knowledge either from billing, reviewing, or processing.
• At least four (4) years medical-surgical clinical experience as a Registered Nurse.
• Minimum four (4) years federal and local policy applications in relation to insurance procedures for medical necessity including the Two Midnight Rule in DRG acute inpatient hospital admissions.
• Current licensure as a Registered Nurse in one or more of the 50 states or D.C.
• Ability to keep sensitive and confidential material private.
• 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).
• Must have and maintain a valid state driver’s license for the state of residence.

 PREFERRED EDUCATION AND EXPERIENCE: 

• Prior utilization review experience in the inpatient setting
• ICD-10-CM, PCS, CPT-4, coding knowledge
• Prior work as a Medicare Contractor Medical Review Nurse
• Optional - Bilingual (Spanish) - Fluency in reading and understanding Spanish language especially as it relates to medical records is a plus!

 Physical Requirements:

• Sitting for long periods
• Standing for long periods
• Ambulate throughout an office
• Ambulate between several buildings

It is the policy of Empower AI to provide equal opportunity in recruiting, hiring, training, and promoting individuals in all job categories without regard to race, color, religion, national origin, gender, age, disability, genetic information, veteran status, sexual orientation, gender identity, or any other protected class or category as may be defined by federal, state, or local laws or regulations. In addition, we affirm that all compensation, benefits, company-sponsored training, educational assistance, social, and recreational programs are administered without regard to race, color, religion, national origin, gender, age, disability, genetic information, veteran status, sexual orientation, or gender identity. It is our firm intent to support equal employment opportunity and affirmative action in keeping with applicable federal, state, and local laws and regulations.  Empower AI is a VEVRAA Federal Contractor.