Lead Claims Review Analyst

Where

Milwaukee, WI

What you'll be doing

Reviewing information contained in standard claims processing system files (e.g., claims history, provider files) to determine provider billing patterns and to detect potentially fraudulent or abusive billing practices or vulnerabilities in Medicare payment policies. Utilizing extensive knowledge of medical terminology, ICD-9-CM, HCPCS Level II and CPT coding along with analysis and processing of Medicare claims. Utilizing Medicare and contractor guidelines for coverage determinations. Coordinating and compiling the written investigative summary report to the program integrity investigator upon completion of the records review.

What your background should be

Must have at least 2 years utilization/quality assurance review and ICD-9-CM/CPT coding experience and a minimum of 5 years clinical experience or equivalent experience in the medical review field. Experience in coding and abstracting, working knowledge of diagnosis related groups (DRGs), prospective payment systems, and Medicare coverage guidelines is required. Advanced knowledge of medical terminology and experience in the analysis and processing of Medicare claims, utilization review/quality assurance procedures, ICD-9-CM and CPT-4 coding, Medicare coverage guidelines, and payment methodologies (i.e., Correct Coding Initiative, DRGs, Prospective Payment Systems, and Ambulatory Surgical Center), NCPDP and other types of prescription drug claims is required. Ability to read Medicare claims, both paper and electronic, and a basic knowledge of the Medicare claims systems is required. Active license as a Registered Nurse (RN). Must have no adverse actions pending or taken against him/her by any State or Federal licensing board or program.

Required Schooling / Training

Graduate from an accredited school of nursing required.

Who is the client company

This is a global, professional services and management consulting company specializing in advanced business analytics and information systems solutions.

If you are interested in this position, send your resume to apply@kochdavis.com