Medical Records Reviewer

Job Description

Job Description

A-Line Staffing is now hiring a Medical Records Content Reviewer in Harrisburg, PA.

Location: Harrisburg, PA 17120

Pay Rate: $20-22.50 per hour based on experience

Schedule: Monday – Friday, 8:00 AM – 4:00 PM

Position Overview:

This position supports the review and evaluation of outpatient healthcare services, medical records, claims, and provider documentation to ensure compliance with state and federal regulations. The Medical Records Content Reviewer is responsible for analyzing claims data, reviewing medical necessity and billing accuracy, evaluating documentation adequacy, and assisting with investigations related to provider compliance and program integrity.

Key Responsibilities:

Claims Analysis:

• Identify discrepancies through analysis of paid claims and various computer reports.
• Review claims for patterns involving high-cost and high-volume providers.
• Identify potential cases requiring further review.

Medical Record Review:

• Select, review, analyze, and evaluate cases retrospectively.
• Monitor compliance with State and Federal regulations.
• Verify services rendered were properly ordered and documented.
• Evaluate medical necessity, quality of care, and billing appropriateness.

Coding & Billing Compliance:

• Analyze claims for upcoding, duplicate billing, and unbundling of services.
• Review compliance with billing guidance and reimbursement requirements.
• Utilize ICD-10-CM diagnosis and procedure manuals, CPT manuals, HCPCS manuals, coding clinics, and related resources.

Case Management & Documentation:

• Prepare case findings and reports.
• Consult with nurse reviewers regarding findings and recommendations.
• Draft preliminary and final provider correspondence.
• Research and apply Medical Assistance regulations, bulletins, and federal regulations.
• Maintain accurate updates within the Case Tracking System.
• Prepare responses to provider and stakeholder correspondence.

Provider Review & Coordination:

• Function as case coordinator for assigned reviews.
• Plan and conduct retrospective review activities.
• Coordinate teleconferences and meetings with providers, consultants, legal counsel, and stakeholders.
• Participate in evidentiary meetings and case strategy discussions.
• Assist with recommendations regarding sanctions and compliance actions.

Reporting & Communication:

• Prepare memoranda, letters, reports, and review documentation.
• Communicate findings to providers, agencies, and stakeholders.
• Respond to complaints received through multiple reporting channels.
• Support special projects and additional assignments as directed.

Required Qualifications:

Education:

• Associate's Degree in Health Services Management OR
• Minimum two (2) years of healthcare management experience.

Preferred Experience:

• Outpatient healthcare services experience.
• Medical record review experience.
• Claims review experience.
• Healthcare compliance experience.
• Program integrity or audit experience.

Technical Skills:

• Knowledge and use of Microsoft Office products.
• Proficiency with Microsoft Excel.
• Strong computer and data analysis skills.

Knowledge & Abilities:

• Understanding of healthcare documentation standards.
• Knowledge of ICD-10-CM, CPT, and HCPCS coding systems.
• Ability to analyze claims and identify billing discrepancies.
• Strong written and verbal communication skills.
• Ability to prepare professional correspondence and reports.
• Ability to comprehend and apply rules, regulations, and policies.
• Ability to establish and maintain effective working relationships.
• Strong organizational and time management skills.
• Ability to maintain discretion and confidentiality.

Additional Requirements:

• Attend required trainings, meetings, hearings, and conferences.
• Ability to testify during legal proceedings when required.
• Ability to physically move materials as needed.
• Ability to complete assignments according to established procedures.

What Candidates Should Know Before Applying:

• This position focuses heavily on medical record review, claims analysis, coding compliance, and provider documentation review.
• Candidates will regularly work with healthcare regulations, coding manuals, and billing guidelines.
• The role requires strong analytical and investigative skills.
• Extensive written documentation and report preparation are required.
• Interaction with providers, legal counsel, consultants, and government stakeholders may occur.
• Candidates must be comfortable reviewing detailed medical and fiscal records.
• Confidentiality and attention to detail are critical to success in this role.

Benefits:

• Benefits are available to full-time employees after 90 days of employment.
• A 401(k) with company match is available after 1 year of service.