Medical Review Specialist Organize and prioritize assigned reviews to make payment determinations in accordance with coding guidelines and medical policies, utilizing expertise in CDT, CPT, ICD, DRG, REV, and HCPCS coding to identify and address potential healthcare fraud schemes. Perform reviews of (pre-payment or post-payment) medical records and healthcare claims, determining the accuracy of codes billed and compliance with appropriate policies, procedures, and regulations. Conduct medical policy and other research relevant to allegations and healthcare claims, determining the accuracy of codes billed and compliance with appropriate policies, procedures, and regulations. Document and prepare well-articulated reports of medical review findings, highlighting key concerns, potential overpayments, and recommendations for payers/clients. Effectively communicate findings to internal teams/leadership and actively support client interactions under supervision. Participate in provider education calls to support medical review findings. Assist in legal proceedings, including testifying and providing evidentiary support for medical review outcomes. Analyze existing policies and processes to identify inefficiencies and propose actionable improvements. Keep up to date with relevant regulations and standards, including federal policies and coding guidelines. Actively engage and support all other projects assigned. Maintain confidentiality and discretion in all medical review/investigative activities.
