Medicare Medical Review Claims Analyst II/Appeals Coordinator -  REMOTE

Company Overview:

CoventBridge Integrity Systems is a national leader in the fight against Fraud, Waste and Abuse (FWA), providing an array of key services that include FWA detection, investigations, clinical evaluation and education and SaaS to federal and state government agencies, commercial healthcare payers and other related entities.  

About the Opportunity:

This position is responsible for organization and entry level review of Medicare and Medicaid claims. Responsible for re-pricing and calculation of overpayments for completed Medical Review post pay case reviews and any re-pricing needed for those review that go through the appeal process. Provides support to Medical Review during the course of fraud investigations or other program integrity initiatives such as requests for information needed to complete Medical Review. Applies a working knowledge of medical terminology and coding principles in the re-pricing of Medicare and Medicaid claims. Also performs such duties as keying information into databases, scanning and assisting with reporting function.

Responsibilities:

• Maintain workflow balance to ensure re-pricing requests are accurately completed within the department’s timeframe established for this work
• Utilize a working knowledge of medical terminology and coding principles in re-pricing claims
• Complete assignments that meet or exceed the quality assurance goal for accuracy
• Implement, terminate and track pre-pay edit requests daily
• Prepare monthly prepay saving report(s) in a timely manner
• Facilitate movement of claims to the UPIC ‘safe locations’ when medical records are received for pre-pay claims
• Adjudicate DME pre-pay claim decisions in VMS
• Facilitate daily adjudication of pre-pay claims based on MR review decisions
• Scan and file Medical Review records and other documents as needed
• Key information into databases and Excel spreadsheets as needed
• Follow all confidentiality and security guidelines regarding PHI and HIPAA protected information
• Perform other duties as assigned by Management that contribute to UPIC goals and objectives and comply with the Program Integrity Manual and Statement of Work guidelines and CMS directives and regulations

Requirements:

• 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) as defined in § 1154(b)(1) of the Social Security Act
• Maintain a valid driver’s license for the associate’s state of residence
• Extensive knowledge of medical terminology and coding principles
• Knowledge of Medicare guidelines and coverage is also required
• Ability to read Medicare/Medicaid claims, both paper and electronic, and a basic knowledge of the Medicare claims systems is required
• Working knowledge of Medicare Claims pricing and payment systems and working knowledge of Medicaid pricing and enhanced rates for states
• Excellent oral and written communication skills
• Ability to work independently with minimal supervision
• Ability to work in MS Office environment
• Extensive knowledge of medical terminology and experience in the analysis and processing of Medicare claims is required as well as experience related to the specific workload of the individual task order, which may be further defined in the Task Order Statement of Work
• One year or more experience in medical terminology and Medicare claims payment systems/Medicaid claims or has attained CPC certification

Educational Qualifications:

• A high school diploma.  Two-year degree with health-care emphasis preferred.
• Certified Professional Coder (CPC) preferred

Benefits:

• Medical, Dental, Vision plans
• Life, LTD and STD paid by the employer
• 401(k) with company match up to 4%
• Paid Time Off and company paid holidays
• Tuition assistance after 1 year of service

The salary range for this role is $50,000 to $55,000 annually. This is the lowest to highest salary we in good faith believe we would pay for this role at the time of this posting. We may ultimately pay more or less than the posted range, and the range may be modified in the future. An employee’s pay position within the salary range will be based on several factors including, but not limited to, relevant education, qualifications, certifications, experience, skills, geographic location, performance, and business or organizational needs.  

Pursuant to the San Francisco Fair Chance Ordinance, we will consider for employment qualified applicants with arrest and conviction records.

About Us:

CoventBridge Integrity Systems delivers investigative services, technology, and expertise that help healthcare and government organizations protect critical programs, strengthen oversight, and address fraud, waste, abuse, and operational risk.

CoventBridge Integrity Systems is an equal opportunity employer. We evaluate qualified applicants without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, caste, disability, veteran status, and other legally protected characteristics and maintains a drug-free workplace.

CoventBridge Integrity Systems is committed to the full inclusion of all qualified individuals. As part of this commitment, CoventBridge Integrity Systems will ensure that persons with disabilities are provided reasonable accommodations. If reasonable accommodation is needed to participate in the job application or interview process, to perform essential job functions, and/or to receive other benefits and privileges of employment, please contact: Human Resources; 888-932-7364; humanresources@coventbridge.com.