• Medical Review Specialist III

    Job ID 2019-3155
    Job Locations
    US-MD-Baltimore | US-Remote
    Healthcare / Biotechnology
    Regular Full-Time
  • Responsibilities

    NCI: As a Medical Review Specialist III (Medical Reviewer III) for AdvanceMed, an NCI Company, you will perform Medicaid/CHIP comprehensive medical record and claims review to make payment determinations.  Perform projects or duties as assigned by the Senior or 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 NCI's mission: To deliver innovative, cost-effective solutions and services that enable our customers to rapidly adapt to dynamic environments.




    • Perform comprehensive medical record and claims review to make payment determinations based on Insurance coverage, coding, and utilization of services and practice guidelines.
    • 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 Medicaid/CHIP claims.
    • Supervising the analysis of provider and service specific claims to identify error.
    • Meeting quality and production standards.  
    • Ensuring departmental compliance with quality managements system and ISO requirements.







    • Bachelor's degree and at least four (4) years claims knowledge either from billing, reviewing, or processing – OR -- Associate's degree and at least six (6) years claims knowledge either from billing, reviewing, or processing – OR -- Diploma in Nursing and at least seven (7) years claims knowledge either from billing, reviewing, or processing.
    • At least three (3) years clinical experience as a Registered Nurse.
    • Minimum four (4) years federal and local policy applications in relation to insurance procedures for medical necessity
    • 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.



    • Medicaid and/or CHIP medical review experience is preferred.
    • One (1) year ICD-10CM coding knowledge.
    • Inpatient InterQual/Milliman screening or similar product experience.
    • For CHIP review, some pediatric nursing experience is preferred.
    • CPMA (Certified Professional Medical Auditor), CDIP (Certified Documentation Improvement Practitioner), RHIT (Registered Health Information Technician), CPC (Certified Professional Coder), CCS (Certified Coding Specialist), CCS-P (Certified Coding Specialist - Physician), or CCA (Certified Coding Associate) are preferred.
    • Bilingual (Spanish) - Fluency in speaking, reading and understanding the Spanish language. 



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