The Medical Review Manager oversees the accurate processing of claims that have been deferred for medical necessity review, ensuring compliance with nationally recognized standards, and local, state, and federal laws and regulations, and identifies and implements process improvement opportunities.
Medical Reviewer Job Description
Medical reviewers work in hospitals, physician offices, nursing homes, and for independent auditing firms. They review or audit medical records for completeness and accuracy by looking at various pieces of documentation. Incorrect or missing documentation can result in loss of hospital accreditation, a physician’s license, or Medicare status. The facility will also lose reimbursement from an insurance company, Medicare, or Medicaid. Too many mistakes in documentation can result in a facility closing.
Medical reviewers often coordinate in-service meetings to educate the medical staff on proper documenting procedures. They also keep abreast of new coding, government, and insurance guidelines.
Medical reviewers look at each individual medical record to check for missing documentation; they also check for physician’s notes that show any evidence of patient neglect or abuse and verify that the correct member of staff has signed all paperwork. When the reviewer finds a problem with the record, a citation is issued to the medical staff member. The member is given a set time period to fix the mistake. A follow-up conducted by the reviewer is done to ensure the record is up to compliance.
- Previous successful work at home experience
- Exposure to Medicare claims processing is a plus
- An active Registered Nurse/RN license in the state the reviewer is working from
- Previous Home Health and Hospice (HHH) review experience highly preferred
- 5 years clinical and utilization review to include 2 years supervisory or team lead experience
- Experience working for a MAC (Medicare Administrative Contractor)
- Experience managing in a production environment
- Understand clinical and regulatory review guidelines
- Familiar with home health and hospice guidelines
- Part A (Hospital/Facility/SNF/Home health/ Hospice) Medical Review experience
- Experience with FISS for Medicare Part A (preferred, not required)
- FISS (Fiscal Intermediary Standard System) – the standard Medicare Part A claims processing system
- In depth knowledge of CMS guidelines, and understanding of Medicare Part A
- Knowledge of government programs and guidelines, medical and legal terminology, and disease management and litigation processes
About BroadPath Healthcare Solutions
BroadPath Healthcare Solutions provides on-demand operational and sales support to health plans and payers in the commercial, Medicare, and Medicaid sectors. Our corporate headquarters is located in Tucson, AZ and we have active employees in 47 states.
Salary Info Medical Review Manager
According to the U.S. Bureau of Labor Statistics (BLS, www.bls.gov), the employment of medical records and health information technicians, including medical reviewers, is expected to grow by 15% between 2014 and 2024. The BLS also reported the median annual salary earned by such specialists as $37,110 in May 2015.
A medical reviewer performs an auditing service for medical institutions, checking various medical data for errors, validity, and completion. To become one, an associate’s degree in health information or a similar field is usually needed. Professional certification is available, which entails passing an exam.
Job Title: Medical Review Manager
Location: work at home – USA
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