Empower AI logo
Empower AI

Empower AI (formerly NCI) elevates public sector teams with the power of AI, to ensure America’s missions are met.

Lead Medical Review Specialist, Medicare

Medical ReviewerMedical ReviewerFull TimeRemoteSeniorTeam 501-1,000Since 1989H1B No SponsorCompany SiteLinkedIn

Location

United States

Posted

1 day ago

Salary

0

Seniority

Senior

Bachelor Degree3 yrs expEnglish

Job Description

Lead Medical Review Specialist, Medicare

Empower AI

• Provide operational support to the Medical Review Manager and the Medical Review Staff in managing production related to claims determinations and review • Serve as a critical component in meeting our mission of providing excellent services to our clients. • Ensure an exciting and rewarding opportunity to be at the forefront of activities related to implementing healthcare reform on a national level. • Review and analyze sampled Medicare claims using associated medical records to make payment determinations based on coverage, coding, and utilization of services. • Make medical necessity determinations utilizing clinical review judgment in accordance with the CERT Program policies and contract responsibilities. • Serve as a resource for medical review specialists involving coverage, coding, and medical necessity issues. • Conduct in-depth claims analysis utilizing ICD-9-CM, ICD-10-CM, CPT-4, and HCPCS Level II coding principles. • Conduct medical record audits to determine the medical necessity and/or appropriateness of medical treatment using CMS and other national guidelines.

Job Requirements

  • Bachelor's degree – OR - Associate's degree – OR - Diploma in Nursing.
  • At least three (3) years claims knowledge either from billing, reviewing, or processing.
  • At least three (3) years clinical experience as a Registered Nurse.
  • Minimum ten (10) years federal and local policy applications in relation to insurance procedures for medical necessity for skilled nursing facility and Part A claim reimbursements.
  • 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).

Benefits

  • Empower AI is a 2024 Military Friendly Employer
  • Equal Opportunity Employer

Related Categories

Related Job Pages

More Medical Reviewer Jobs

TELUS Digital logo

Online Ads Reviewer

TELUS Digital

At TELUS Digital, we are proud to be an equal opportunity employer and are committed to creating a diverse and inclusive workplace. All aspects of employment, including the decision to hire and promote, are based on applicants’ qualifications, merits, competence and performance without regard to any characteristic related to diversity.

Full TimeRemoteTeam 10,001

Role Description You’ll help shape AI used by millions every day. As a Digital Ads Quality Analyst, you’ll review online ads and provide real human feedback that makes digital advertising smarter, safer, and more relevant for users in Türkiye and across Europe — all from home, on your own schedule. - Evaluate how well ads match what users in Türkiye and German‑speaking markets are searching for - Assess ad quality, language accuracy, and cultural relevance - Provide clear, honest feedback to improve ad performance - Contribute your human perspective to AI training - Work at your own pace, task by task Qualifications - Fluent in German and English (professional level) - Living in Türkiye (local cultural knowledge is essential) - Regular experience using social media and browsing the web - Reliable internet connection and a computer with antivirus - A smartphone (Android 4.1+ or iOS 8+) - Strong attention to detail and good communication skills - An English CV ready to upload Requirements - Language Check — Show your English and German skills - Knowledge Exam — Open‑book, with study materials provided - ID Verification — Standard security step Benefits - Support Designed for Remote Work - 24/7 confidential access to emotional, psychological, and practical support - 90‑day aftercare after leaving the program - Free Headspace Premium for mindfulness, focus, and better sleep - Fast support with responses within 24 hours - Proactive protection against stressful content - Regular wellbeing resources and training - Join 1M+ human raters improving AI for leading global technology companies - Be part of a diverse international community of digital professionals - See your work influence technology used worldwide - 100% remote — work from anywhere in Türkiye - Fully flexible hours (long‑term project) - No previous professional experience required

Turkey
Health Care Service Corporation logo

Medical Reviewer II

Health Care Service Corporation

Empowering Whole Person Health With Compassion and Innovation

Full TimeRemoteTeam 10,001+H1B Sponsor

• Perform accurate and timely medical review of claims suspended for medical necessity • Initiate and/or respond to correspondence from providers or members concerning medical determinations

Illinois + 4 moreAll locations: Illinois | Montana | New Mexico | Oklahoma | Texas
$61.5K - $136.1K / year
Verse Medical logo

Medical Review Nurse

Verse Medical

At Verse, we're building software that enables hospital-quality care at home. We're freshly funded by top healthcare and technology investors, including Y Combinator, Abstract Ventures, Josh Buckley and Paul Graham (founder of Y Combinator). We're growing our team aggressively across every department. If you're interested in working on software that changes how healthcare is delivered, please reach out!

Role Description This isn't just a job; it's a chance to build something that matters. As Medical Reviewer, you'll be shaping the future of at-home care. You'll be a key part of the team, working to ensure each surgical dressing order is fully compliant with every CMS regulation, including regulation/policies as they are applied by MACs & UPICs. You’ll translate LCDs/Articles and MAC playbooks into checklists, fix packet defects pre-bill, and run our ADRs/appeals processes. Your Contributions - Policy → Practice - Interpret and operationalize LCD L33831 + Policy Article for surgical dressings; publish practical rules (when covered, limits, documentation phrases). - Stand up “go/no-go” criteria for collagen, alginate/fiber-gelling, foam, film, hydrocolloid; codify A-modifier (wound count) usage, KX/GA/GZ/EY, sizing, quantity/frequency math. - Pre-Bill Controls - Build a 2-gate QA (1: clinical completeness; 2: billing correctness) and pilot it on all surgical-dressing claims. - Create/upgrade templates for various outreach. - Audit & Appeals - Lead UPIC/MAC ADR responses (pre- and post-pay). - Coach internal billing team; establish a reusable appeals library with policy citations and exemplars. - Enablement & Analytics - Train customer-facing team members (30-min modules) and billers on the specific documentation that satisfies the LCD. - Define and track metrics: initial denial %, appeal win %, ADR turnaround, % packets with signed POD, top-defect Pareto. Qualifications - 3-5+ years medical-review experience at a UPIC or MAC (e.g., Safeguard Services, Qlarant, CoventBridge; Noridian, CGS, NGS, WPS, Novitas, Palmetto). - Hands-on adjudication of surgical dressings (A6021 collagen; A6196–A6199 alginate/fiber-gelling; A6209–A6215 foam; A6212–A6214 bordered foam; A6216–A6221 gauze; A6257–A6259 film). - Expert with proof-of-delivery standards, SWO requirements, frequency/sizing rules, and common denial rationales (e.g., two-cover stacking, over-frequency without rationale, DOS/POD mismatch). - Crisp, policy-anchored writing; calm under deadline; disciplined with PHI. Our Pledge for an Equitable Future At Verse Medical, our mission is to deliver equitable, hospital-quality care to everyone, regardless of their background or where they live. We can only achieve this if our own team reflects the diversity of the patients we serve. We are committed to building a workplace where everyone feels a sense of belonging, where their contributions are valued, and where they can do their best work. We embrace diversity of all kinds: race, gender, age, religion, identity, experience. We are actively working to build a more inclusive and equitable world, starting from within our own walls. We are an equal opportunity employer. We are also committed to providing a positive and accessible interview experience. If you require any accommodations to participate in our process, please contact us at recruiting@versemedical.com.

United States

Prior Approval Reviewer

State of Illinois

The State of Illinois, otherwise known as the "Prairie State," was the 21st territory inducted into the United States in 1818. The state name derives from a Nat

Role Description The Department of Healthcare and Family Services, Bureau of Professional and Ancillary Services is seeking to hire a motivated candidate to serve as a Prior Approval Reviewer. Under the direction of the Prior Approval and Customer Relations section manager, this position will serve as a specialized physician reviewer for the Medical Review Unit. The duties for this position may include but are not limited to: - Providing expert medical/clinical, consultative, program and policy advisory services related to specialized medical equipment and services to staff. - Convening regular meetings with staff to participate in developing, implementing and maintaining system changes or policy decisions that may impact medical services to individuals eligible for Medical Assistance. - Participating in developing medical criteria options for program coverage of durable medical equipment, supplies and other covered services. The ideal candidate will have strong communication skills, excellent team leadership skills, ability to thrive in a high volume and fast paced environment and demonstrate the ability to collaborate with team members to ensure operations are running effectively. Qualifications - Requires an Illinois license to practice medicine. Requirements - A minimum of two (2) years of experience making clinical prior approval decisions including, working with complex medical data, and familiarity with medical coding such as ICD-10CM, CPT or HCPCSs. - A minimum of two (2) years of professional experience communicating with medical providers on behalf of a payer regarding billing codes and rejection codes as well as medical terminology. - Requires two (2) years of experience working with Medical Management Information Systems (MMIS) or similar medical processing system. Benefits - Monday-Friday work schedule. - Flexible work schedules are available in many program areas. (Remote work may be an option for certain positions.) - Health, Life, Vision, and Dental Insurance. - Pension Plan. - Paid Parental Leave. - Deferred Compensation Program and other pre-tax benefit programs (Medical/Daycare). - Employees earn (12) paid Sick Days annually. - New Employees earn (10) paid Vacation Days their first year of service and can earn up to (25) paid Vacation Days annually. - Employees earn (3) paid Personal Days annually. - (13-14) paid holidays annually (based on start date). Company Description At the Illinois Department of Healthcare and Family Services (HFS), we value staff as our greatest asset. We work in a spirit of teamwork to help millions of Illinoisans access high quality healthcare and fulfill child support obligations to advance their physical, mental, and financial well-being. We provide healthcare coverage for children and adults through Medicaid and other medical programs, and we help ensure that children receive financial resources from both their parents through Child Support Services. The HFS Office of the Inspector General investigates, audits and reviews program activity to ensure the integrity of our programs is maintained. HFS is committed to promoting and preserving a workplace culture that embraces diversity, equity, and inclusion. We welcome and value employees with different backgrounds, life experiences, and talents. It is the collective sum of our individual differences that provides a broad perspective, leading to greater innovation and achievement. In recruiting for our team, we recognize the unique contributions of each applicant regardless of culture, ethnicity, race, national origin, sex, gender identity and expression, age, religion, disability, and sexual orientation. HFS is an equal opportunity employer.

United States
$13.1K - $17.9K / month