Lead Medicare Claims Reviewer (RN)
We are a fast growing government contractor specializing in custom analytics and information management and support the Federal Government in the areas of healthcare, defense, and intelligence. We offer a generous benefits package. Come join other highly qualified professionals providing outstanding service to our customers.
Catapult Consultants is a global, professional services and management consulting company specializing in business, analytical and information systems solutions with top talent who create exceptional results for our clients. We support mission-critical programs in the Intelligence Community and Defense and Civilian sectors with our team of smart, energetic people who like taking on big challenges and are committed to not just checking the box but exceeding client expectations. The Catapult culture is defined by mutual respect, hard work, and teamwork. We recognize that a great idea can come from anyone at any time, so we encourage innovative thinking and the sharing of ideas.
The Lead Medicare Claims Reviewer (RN) is primarily responsible for conducting clinical reviews of medical records during the course of fraud investigations or other program integrity initiatives such as requests for information or in support of proactive data analysis efforts. This person applies Medicare guidelines in making clinical determinations as to the appropriateness of payment coverage.
• 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-9-CM, HCPCS Level II and CPT coding along with analysis and processing of Medicare claims. Utilizes Medicare and Contractor guidelines for coverage determinations.
• Coordinates and compiles the written Investigative Summary Report to the Investigator upon completion of the records review.
• Incorporates leadership and communication skills to work with physicians and other health professionals as well as external regulatory agencies and law enforcement personnel.
• Provides training to ZPIC staff on medical terminology, reading medical records, and policy interpretation.
• Provides expert witness testimony as required.
• Completes assignments in a manner that meets or exceeds the quality assurance goal of 98% accuracy.
• Maintains chain of custody on all documents and follows all confidentiality and security guidelines.
• Performs other duties as assigned by the Medical Review Supervisor that contribute to ZPIC goals and objectives and comply with the Program Integrity Manual and Statement of Work guidelines and CMS directives and regulations.
• 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
• At least 5 years utilization/quality assurance review and ICD-9-CM/CPT coding experience DRG codes.
• Should possess excellent oral and written communication skills.
• Knowledge of and ability to use Microsoft Word, Excel and Internet applications.
• Able to efficiently organize and manage workload and assignments.
• Previous Medicare Medical Review experience is preferred. Experience reviewing medical claims to determine medical necessity and appropriateness is preferred.
• Minimum of 5 years clinical experience or equivalent experience in the Medical Review field.
• Ability to pass a background check.
EEO StatementCatapult Consultants is an Equal Opportunity Employer.
We believe that every employee has the right to work in a dignified work environment free from all forms of discrimination and harassment. It’s our policy to recruit, employ, retain, compensate, train, promote, discipline, terminate and otherwise treat all employees and job applicants based solely on qualifications, performance, and competence. This policy reflects our belief that providing equal opportunities for all employees is a both our legal and moral responsibility, and good management practice.
All employees and applicants are treated without regard to age, sex, color, religion, race, national origin, citizenship, veteran status, current or future military status, sexual orientation, gender identification, marital or familial status, disability or any other status protected by law.
The above statements are intended to describe the general nature and level of work being performed by people assigned to this classification. They are not to be construed as an exhaustive list of all responsibilities, duties, and skills required of personnel so classified. All personnel may be required to perform duties outside of their normal responsibilities from time to time, as needed.