Medical Review Specialist III

Medical Review Specialist The Centers for Medicare & Medicaid Services (CMS) Comprehensive Error Rate Testing (CERT) program plays a vital role in safeguarding the integrity of the Medicare Fee-for-Service (FFS) program by ensuring that taxpayer-funded healthcare payments are accurate, appropriate, and compliant with federal requirements. The insights generated through CERT enable CMS to strengthen accountability, improve healthcare delivery practices, and drive corrective actions that protect both beneficiaries and public funds. Through this work, the CERT program helps uphold transparency, stewardship, and trust in one of the nation's most critical healthcare systems. This position requires experience in working with case management of medical records, abstraction, and complying with policies for obtaining missing/incomplete medical record documentation. The Medical Records Case Review Specialist must have experience with medical records, knowledge of what constitutes required documentation in inpatient/outpatient medical records, physician office records, laboratory/radiology, and other types of medical records in order to provide first level expertise in clinical documentation review. ICD-9-CM/ICD-10-CM, CPT-4 coding experience is invaluable as well. As a Medical Review Specialist, you will: Conducts in-depth claims analysis utilizing ICD-9-CM, ICD-10-CM, CPT-4, and HCPCS Level II coding principles Applies the interpretation of ANSI Reason Codes, Revenue Codes, timely MAC Edits and Audit codes, and other Medicare billing formats in order to determine appropriate billing submissions and reimbursement Conducts medical record audits to determine the medical necessity and/or appropriateness of medical treatment using CMS and other national guidelines, as well as national and local coverage decision determinations Provides electronic documentation of findings and conclusions with determinations of claims payment appropriateness in review tool fields Reviews and completes the required number of claims reviews in accordance to established production standards for the project Communicates internally with all levels of CERTParticipates in QA and IRR monitoring as requested Complies with departmental policies and procedures Complies with Program Integrity Manual (PIM) and Statement of Work (SOW) guidelines and CMS directives and regulations pertaining to integrity, fraud, overpayments, and the handling and disclosure of information Attends departmental and required education and training programs Performs other projects or duties as assigned by the Medical Review Manager, Deputy Medical Review Manager, or Lead Medical Review Specialist To be successful in this role, you must have: Bachelor's degree Medical record knowledge and experience in order to determine complete medical records Knowledge of ICD-9-CM, ICD-10-CM and CPT-4 coding in order to determine services rendered. Good organizational skills. Knowledge of Microsoft office programs and databases Additional desired qualifications:5-7 years of medical review experience Serco Inc. (Serco) is the Americas division of Serco Group, plc. In North America, Serco's 9,000+ employees strive to make an impact every day across 100+ sites in the areas of Defense, Citizen Services, and Transportation. We help our clients deliver vital services more efficiently while increasing the satisfaction of their end customers. Serco serves every branch of the U.S. military, numerous U.S. Federal civilian agencies, the Intelligence Community, the Canadian government, state, provincial and local governments, and commercial clients. Wherever you work and whatever you do, we invite you to discover your place in our world. Serco is a place you can count on and where you can make an impact because every contribution matters. Serco is an equal opportunity employer. We evaluate qualified applicants without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, veteran status, and other legally protected characteristics.