A company is looking for a Medical Reviewer III - Managed Care Project (MCP).
Key Responsibilities
Conduct clinical reviews of medical records for the Medicaid Managed Care Project (MCP) and apply Medicaid guidelines for payment coverage determinations
Develop review criteria and ensure claims are accurately paid based on project plans and documentation
Compile Investigative Summary Reports and collaborate with healthcare professionals and regulatory agencies
Required Qualifications, Training, and Education
Active Registered Nurse (RN) license from an accredited nursing school
Minimum of 4 years of experience in utilization / quality assurance review and ICD-10-CM / CPT-4 coding
Experience in coding and abstracting with knowledge of Diagnosis Related Groups (DRGs)
Advanced understanding of medical terminology and Medicaid claims processing
Familiarity with Medicaid coverage guidelines and payment methodologies
Rn Medical • Lincoln, Nebraska, United States