Talent.com
Empower AI
Medical Review Specialist III (DRG Claims)Empower AI • Richmond, VA, United States
No longer accepting applications
Medical Review Specialist III (DRG Claims)

Medical Review Specialist III (DRG Claims)

Empower AI • Richmond, VA, United States
11 days ago
Job type
  • Full-time
Job description

Medical Review Specialist III

Empower AI: As a Medical Review Specialist 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 management 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

About Empower AI: 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.

Create a job alert for this search

Medical Review Specialist III (DRG Claims) • Richmond, VA, United States

Similar jobs

Director of Crisis Services

St. Joseph's VillaRichmond, VA, United States
Full-time

Director of Clinical Services, the Crisis Services Director provides strategic leadership, administrative oversight, and operational accountability for Crisis Services programs, including the Crisi... Show more

 • Promoted

Associate Claims Examiner

Kinsale InsuranceRichmond, VA, United States
Full-time

Kinsale Insurance Associate Claims Examiner.Are you a recent college graduate or considering a career change? Kinsale Insurance has a proven track record of helping candidates like you build reward... Show more

 • Promoted

Medical Director (MD/DO) – Addiction Medicine | Behavioral Health

New SeasonRICHMOND, VA, US
Part-time

Medical Director (MD/DO) – Addiction Medicine | Behavioral Health.New Season Treatment Centers is a national leader in outpatient addiction treatment, providing Medication-Assisted Treatment (MAT),... Show more

Associate Director Sterility Assurance

Civica RXPetersburg, VA, United States
Full-time

About Civica:Critical shortages of essential generic injectable drugs are an ongoing crisis in U.Over 300 essential medications are currently reported to be in shortage, according to industry and F... Show more

 • Promoted

CDL A Dedicated Regional Reefer Driver in Ruther Glen, VA

NFI IndustriesRuther Glen, VA, United States
Full-time

NFI Industries is hiring CDL A Dedicated Regional Reefer Drivers in Ruther Glen, VA.NFI is one of the largest dedicated transportation companies in North America.Family owned and operated for over ... Show more

 • Promoted

Director of Clinical Services

PristigeRichmond, VA, United States
Full-time

As a Director of Clinical Services at Prestige Healthcare Services, you will play a critical role in leading our clinical team to deliver exceptional patient care and outcomes.Reporting directly to... Show more

 • Promoted

Insurance Follow Up Specialist - East

Universal Health ServicesRichmond, VA, United States
Full-time

ResponsibilitiesAtlantic Region CBO:The Atlantic Region Central Billing Office (ARCBO) or (CBO) provides business office services including billing, collections, cash posting, pre-access management... Show more

 • Promoted

Home Health Clinical Manager

CenterwellRichmond, VA, United States
Full-time

Now offering a $10,000 Sign On Bonus!! As a Clinical Manager at CenterWell Home Health, reporting to the Branch Director, you will lead and support a team of dedicated clinicians who deliver compas... Show more

 • Promoted

Director of Surgical Services, RN

She Recruits LLCChester, VA, United States
Full-time

Director of Surgical ServicesLocation: Hopewell, VAJob Type: Full-Time, Days (No Weekends)Compensation: $95,000 - $155,000(based on experience)Bonus Structure: 15% Annual Director BonusSign-On/Relo... Show more

 • Promoted

Director, Claims Triage

Argo GroupRichmond, VA, United States
Full-time

Argo Group is an underwriter of specialty insurance products in the property and casualty market.Argo offers a full line of products and services designed to meet the unique coverage and claims-han... Show more

 • Promoted

Home Health Aid

HCAOARuther Glen, VA, United States
Part-time

Skilled Caregivers And Home Health Aids Wanted.Right at Home, In-Home Care & Assistance, is seeking to hire skilled caregivers and home health aids to join a dynamic care team providing clinical ex... Show more

 • Promoted

Healthcare Assistant

MedullaColonial Heights, VA, United States
Full-time

TVG-Medulla, LLC is a multi-site healthcare management organization, with an emphasis on providing managed services to chiropractic providers.Medulla provides managed services such as Sales & Marke... Show more

 • Promoted

Patient Care Specialist III

Pinnacle Treatment CentersRichmond, VA, United States
Full-time

Patient Care Specialist III- AmbulatoryPinnacle's Voice:A Tale of Transformation & RecoveryShift:3:30 pm - MidnightAs a Patient Care Specialist- III of Ambulatory Services (PCS-III AMB), you ar... Show more

 • Promoted

Regional Flatbed Truck Driver - up to $1,800/wk

Boyd Bros. Transportation Inc.Doswell, VA, United States
Full-time

Mon-Fri schedule that gets you home 1+ nights a week.Sign on bonus + orientation pay.Now under new management, Boyd is focused on what drivers want most: more home time, better planning, and expand... Show more

 • Promoted

Dedicated CDL A Truck Driver - $85,800-$93,600/year

Hogan TransportationRappahannock Academy, VA, United States
Full-time

CDL-A Truck Drivers – No Touch Freight – Earn $85,800-$93,600 Annually.Sign-On Bonus for Experienced Drivers.Sign-On Bonus for Experienced Drivers (.Weekend Pay incentives up to $200 per week.Unlim... Show more

 • Promoted

Work From Home

Remote JobsMilford, VA
Remote
Full-time

Remote Jobs are now available in your area.This position is a work from home position.You will not need to come into the office.Benefits: Health Insurance, 401K, Vacation& PTO.Apply now! Work f... Show more

 • Promoted

Reimbursement Specialist - Ambulatory - Days - Remote

Virginia Commonwealth University Health SystemsRichmond, VA, United States
Remote
Full-time

Remote:To the Virginia area only.The Reimbursement Specialist improves revenue collection pertaining to high cost medications that require prior authorization.This job will initiate, follow-up, and... Show more

 • Promoted

Senior Oncology Account Specialist TIVDAK Baltimore MD

PfizerRichmond, VA, United States
Permanent

Job DescriptionROLE SUMMARYEverything we do, every day, is in line with an unwavering commitment to the quality and the delivery of safe and effective products to patients.Our science and risk-base... Show more

 • Promoted

Risk Management Director, RN, BSN

Southern Medical RecruitersRichmond, VA, United States
Full-time

Risk Management Director, RN, BSN.Director of Risk Management needed for healthcare organization.Candidates must have strong experience and results as Dir.Director experience of at least 6+ years w... Show more

 • Promoted

Drivers Needed in Richmond

LyftRuther Glen, VA, United States
Full-time +1

Get a maximum of $400 in bonuses in Richmond.Earn $100 for every 10 rides in 7 days (limit 4).Lyft is a flexible earning opportunity and a platform that connects drivers with individuals that need ... Show more