Qureos Mentor

CES, LLC

<div>Job Description Summary: 
The Claims Analyst ensures the review and analysis of sampled Medicaid claims using associated medical records; makes payment determinations based on coverage, coding, utilization of services and practice guidelines; and makes medical necessity determinations utilizing clinical review judgment in accordance with the PERM Program policies and contract responsibilities. The period of performance for this role is from 12/1/2025-3/15/2026. 
 
Duties/Responsibilities: 
<ul><li>Conducts in-depth claims analysis utilizing ICD-9-CM, ICD-10-CM, CPT-4, APR-DRG, and HCPCS Level II coding principles</li>
<li>Conducts medical record audits to determine the medical necessity and/or appropriateness of medical treatment as defined by the Statement of Work and CMS directives as well as State specific regulations pertaining to Medical necessity</li>
<li>Reviews the Master Policy List and the MR questionnaire and develops State Fact Sheets and Resource Page for each assigned State prior to the review of claims for that State</li>
<li>Functions as the policy and regulation expert in assigned states</li>
<li>Provides electronic documentation of findings and conclusions with determinations of claims payment appropriateness in review tool fields</li>
<li>Reviews and completes the required number of claims reviews in accordance to established production standards for the project</li>
<li>Communicates internally with all levels of PERM staff</li>
<li>Attend assigned State meetings</li>
<li>Participates in QA and IRR monitoring as requested</li>
<li>Complies with departmental policies and procedures</li>
<li>Comply with QA benchmarks established by the PERM MR department</li>
<li>Attends departmental and required education and training programs</li>
<li>Performs other projects or duties as assigned by the Senior Medical Review Specialist</li>
</ul>
 
Required qualifications/skills: 
<ul><li>Graduate from an accredited Registered Nurse (RN) school (associate degree or diploma based) or Bachelor's Degree (preferred) with active state licensure in one or more of the 50 states or D.C.</li>
<li>Ability to comprehend medical policy and criteria to clearly articulate health information</li>
<li>Team-oriented and able to implement the operational strategies and procedures that will help achieve the overall quality and production goals of the Medical Review unit</li>
<li>Knowledge of ICD-10-CM and CPT-4 coding</li>
<li>Minimum three years of experience in a clinical setting with experience evaluating medical necessity of services, diagnosis and procedure coding and appropriateness of clinical settings.</li>
<li>Inpatient Interqual/Milliman screening or similar product experience preferred</li></ul></div>

Medical Claims Analyst (RN)

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CES, LLC

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Medical Claims Analyst (RN)