Job Summary - As Needed – Estimated 225 Hours Total
This position is responsible for providing medical insight and expertise for Medicare and Medicaid claims review decisions, providing expert testimony as needed, presenting medical education sessions as needed.
Essential Duties and Responsibilities
Provide specialty medical insight and expertise for Medicare and Medicaid claims review decisions and national coverage payment issues.
Utilize extensive knowledge of medical terminology, ICD-10-CM, HCPCS Level II and CPT coding along with analysis and processing of Medicare or Medicaid claims. Utilize Medicare and Contractor guidelines for coverage determinations. Utilize state specific guidelines and regulations for claim determinations.
Coordinate and compile written medical review summary of findings in conjunction with PI Investigators upon completion of the records review.
Maintain working knowledge of medical practice standards, guidelines, and related technology.
Assist with development of contractor policy, including necessary updating of policies and the development of written guidelines used by the UPIC.
Complete assignments in a manner that meets or exceeds the quality assurance goal of 95% accuracy.
Present medical specialty education sessions as needed.
Provide expert testimony as required.
Maintain chain of custody on all documents and follows all confidentiality and security guidelines.
Ensure compliance with PIM guidelines and CMS directives concerning Medical Review and supports hearings and appeals.
Perform other duties as assigned by the Medical Review Manager or Jurisdiction Program Director that contribute to UPIC goals and objectives.
Competencies
To perform the job successfully, an individual should demonstrate the following competencies:
Knowledge of, and the ability to correctly identify, Medicare and Medicaid coverage guidelines.
Excellent verbal and written communication skills.
Extensive knowledge of the Medicare and Medicaid programs, particularly the coverage and payment rules.
Able to efficiently organize and manage workload and assignments.
Education and Experience
Board certified Doctor of Medicine or a Doctor of Osteopathy with a Vascular Surgery Specialty recognized by the American Board of Medical Specialties. Must have been board certified for at least 5 years.
Must have an active valid and unrestricted license.
Must be currently licensed to practice medicine in at least one U.S. state, territory, or the District of Columbia.
Must have a minimum of 5 years practicing medicine as a board-certified Doctor of Medicine or Osteopathy.
Prior work experience in the health insurance industry, a utilization review firm, or another health care claims processing organization in a role that involved developing or reviewing coverage or medical necessity policies and guidelines.
Public relations experience such as collaborating with physician groups, beneficiary organizations, and/or congressional offices is preferred.
Must have no adverse actions pending or taken against him/her by any State or Federal licensing board or program.
Ability to read Medicare claims, both paper and electronic, and a basic knowledge of the Medicare claims systems is required.
Ability to read a Medicaid claim and basic knowledge of Medicaid claims.
Must have no conflict of interest (COI) as defined in 1154(b) (1) of the Social Security Act.