Medical Reviewer III (Medicare/DRG)

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 2024 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.

• →Perform comprehensive medical record and claims review to make payment determinations based on Insurance coverage, coding, and utilization of services and practice guidelines for Medicare DRG.
• →Performs first level of Medical Review in determination of claims payment review
• →Conducts in-depth claims analysis utilizing ICD-10-CM, CPT-4, and HCPCS Level II coding principles
• →Utilize electronic health information imaging and input 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.
• →Meeting quality and production standards.  
• →Ensuring departmental compliance with quality managements system and ISO requirements.
• →Completes other projects or duties assigned by the Medical Review Lead Specialist

• 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.
• Minimum two (2) years federal and local policy applications in relation to Medicare insurance procedures for medical necessity for Physician Office practices, Laboratory, and Ambulance Services.
• 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).

• Physician Office, Hospital, Suppler, or Clinic providing DME equipment care/services
• Prior work as a Medicare Contractor Medical Review Nurse or Commercial Insurance
• Optional - Bilingual (Spanish) - Fluency in reading and understanding Spanish language especially as it relates to medical records is a plus!

This position requires the ability to perform the below essential functions:

• Sitting for long periods
• Standing for long periods

All hiring and promotion decisions at Empower AI are based on merit to bring the best talent available to contribute to our firm’s overall success. It is the policy of Empower AI not to discriminate against any applicant for employment, or employee because of age, color, sex, disability, national origin, race, religion, or veteran status. Empower AI is a VEVRAA Federal Contractor.