Medical Reviewer III – Managed Care Project (MCP), Anywhere

2025-5902 The Medical Reviewer III (MCP) will be responsible for conducting clinical reviews of medical records for the Medicaid Managed Care Project (MCP). Applies Medicaid guidelines in making clinical determinations as to the appropriateness of payment coverage. In assuming this position, you will be a critical contributor to meeting CoventBridge Group's objective: To provide services to our clients that exceed their expectations and contribute to improved healthcare delivery by identifying and eliminating fraud, waste and abuse. This position will report directly to the Medical Review Supervisor and will work in our Grove City, OH office. If not local, remotely from a home office. Responsibilities/ Requirements Responsibilities:

• Using knowledge of Medicaid state and federal laws, rules, and regulations, to contribute to the development of review criteria to be approved for use in the review of claims
• Review information contained in project plan to ensure claims are paid correctly, documentation supported services as provided, etc.
• Utilize extensive knowledge of medical terminology, ICD-10-CM, HCPCS Level II and CPT coding along with analysis and processing of Medicaid claims; Utilize MCP guidelines for coverage determinations, and utilize state specific guidelines and regulations for claim determinations
• Coordinate and compile written Investigative Summary Reports in conjunction with PI Investigators upon completion of the records review
• Uses leadership and communication skills to collaborate with physicians and other health professionals, as well as external regulatory agencies and law enforcement personnel
• Provide expert witness testimony as required
• Complete assignments in a manner that meets or exceeds the quality assurance goal of 95% accuracy
• Maintains chain of custody on all documents and follows all confidentiality and security guidelines
• Perform other duties as assigned by the Medical Review Supervisor that contribute to UPIC goals and objectives, comply with the Program Integrity Manual (PIM), Statement of Work (SOW) guidelines, and CMS directives and regulations

Requirements:

• Knowledge of, and the ability to correctly identify Medicaid coverage guidelines
• Ability to read a Medicaid claim and basic knowledge of Medicaid claims
• Excellent verbal and written communication skills
• Knowledge of and ability to use Microsoft Word, Excel, and Internet applications
• Ability to efficiently organize and manage workload and assignments

Educational/Experience Qualifications:

• Graduated from an accredited school of nursing and has an active license as a Registered Nurse (RN)
• At least 4 years’ utilization/quality assurance review and ICD-10-CM/CPT-4 coding experience
• At least 4 years’ experience in coding and abstracting; working knowledge of Diagnosis Related Groups (DRGs) is required
• Advanced knowledge of medical terminology and experience in the analysis and processing of Medicaid claims, utilization review/quality assurance procedures, ICD-10-CM and CPT-4 coding, Medicaid coverage guidelines, and payment methodologies (i.e., Correct Coding Initiative, DRGs), NCPDP and other types of prescription drug claims is required

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 $65,000 to $75,000 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 Group is the global leader in full-service investigations providing Surveillance, SIU and Compliance, Claims Investigation, Counter-Fraud Programs, Desktop Investigations, Social Media, Record Retrieval, Canvasses and Vendor Management programs. The company provides top tier data privacy and security practices, deploys robust case management technology customized to clients’ needs and delivers worldwide coverage via its 1000 employees and affiliates worldwide. CoventBridge 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 is committed to the full inclusion of all qualified individuals. As part of this commitment, CoventBridge 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; [email protected]. Apply tot his job Apply To this Job