Medical Management - Certified Medical Review Examiner 145-2001

JOB SUMMARY:

Responsible for auditing provider and facility claims against relevant medical records and documents. Audits verify coding accuracy, benefit payment, contract interpretation, and overall compliance with established guidelines and standards. Participates in various projects aimed at identifying areas of non-compliance and/or potential fraud, waste and abuse, as it relates to coding and provider billing practices.

KEY RESPONSIBILITIES:

• Identifies areas of potential non-compliance and/or potential fraud, waste and abuse. Participate in special projects, audits and internal committees as assigned. Assist in the development and/or revision of process workflows and payment policies.
• Provide review of complex claims for additional research that meet the MRE "pend" criteria. Collaborate with Medical Director and/or other departments (and resources) to make claim determinations.
• Maintain tracking database including self-audit for quality control. Compile data and prepare routine reports as assigned. Identify trends from claim reviews. Suggest opportunities for special study. 
• Determine appropriateness for further review. Request medical records and other documents to evaluate for appropriateness, coding compliance and validity of charges. Document ineligible charges and provide communications internally for claims processing and externally to providers.
• Serve as an internal resource to provider services, contracting, claims, medical management, configuration, and appeals & grievances (including re-review of denied MRE charges for Level 1 appeals). Provide guidance on operational or procedural issues as it relates to coding and billing practices. Participate in provider education upon request.
• Performs other duties as assigned.

QUALIFICATIONS:

• • Extensive knowledge of ICD-10, HCPS, CPT-4 codes.
  • Able to work independently and meet stringent deadlines.
  • Strong attention to detail.
  • Proficient in Microsoft applications.
  • Successful completion of Health Care Sanctions background check.
  • Possess strong oral and written communication skills.

EDUCATION/EXPERIENCE:

• • Coding Certification nationally recognized by the AAPC or AHIMA for a minimum of 5 years.  
  • Minimum of 5 years combined employment in both facility and provider health care settings.
  • Previous HMO or health insurance experience preferred.
  • Experience or familiarity with state and federal regulations governing health care.