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Medical Reviewer III

4 weeks ago

Fredericksburg, Virginia, United States Catapult Consultants Full time

Job Summary:

Catapult Consultants is seeking a skilled Medical Reviewer III to join our team. As a Medical Reviewer III, you will be responsible for conducting clinical reviews of medical records during the course of fraud investigations or other program integrity initiatives.

You will apply Medicare guidelines in making clinical determinations as to the appropriateness of payment coverage. Your expertise will be utilized to review information contained in Standard Claims Processing System files to determine provider billing patterns and detect potentially fraudulent or abusive billing practices.

Key Responsibilities:

  • Conduct clinical reviews of medical records to detect potential fraud or abuse
  • Apply Medicare guidelines to make clinical determinations
  • Review information contained in Standard Claims Processing System files
  • Utilize extensive knowledge of medical terminology, ICD-9-CM and ICD-10-CM, HCPCS Level II and CPT coding
  • Coordinate and compile written Investigative Summary Reports
  • Maintain chain of custody on all documents and follow confidentiality and security guidelines

Requirements:

  • At least 4 years' experience in coding and abstracting
  • Working knowledge of Diagnosis Related Groups (DRGs), Prospective Payment Systems, and Medicare coverage guidelines
  • Advanced knowledge of medical terminology and experience in the analysis and processing of Medicare claims
  • Ability to read Medicare claims, both paper and electronic

What We Offer:

Catapult Consultants offers a dynamic and challenging work environment with opportunities for professional growth and development. We are committed to providing our employees with the tools and resources they need to succeed.