Medical Reviewer III (Medicare DME claims)

Responsibilities:

• Perform comprehensive medical record and claims review to make payment determinations based on Insurance coverage.
• Perform first and second level of Medical Review in determination of claims payment review.
• Utilize electronic health information imaging and input medical review decisions by electronic database module.

Qualifications:

• Must be a Registered Nurse obtained by either a Bachelor's degree – OR - Associate's degree – OR - Diploma in Nursing.
• At least four (4) years claims knowledge either from billing, reviewing, or processing of Durable Medical Equipment.
• At least three (3) years clinical experience as a Registered Nurse.

Requirements:

• Minimum four (4) years federal and local policy applications in relation to Medicare insurance procedures for medical necessity.
• Current licensure as a Registered Nurse in one or more of the 50 states or D.C.
• 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).