Medical Review Subject Matter Expert

**Position Description**

Serco is seekinga motivated Medical Review Subject Matter Expert to join our talented and fast-paced Public Sector Solutions team in supporting CMS’ implementation of the Payment Error Rate Measurement (PERM) Program to produce national Medicaid and Children’s Health Insurance Program (CHIP) improper payment estimates as required by the Payment Integrity Information Act of 2019 (PIIA).

As part of this effort, Serco would execute the PERM review contract which includes collection of state eligibility policies and medical records; medical reviews, data processing reviews, and eligibility reviews of selected state Medicaid and CHIP fee-for-services (FFS) and managed care claims; and supporting state and national reporting and development of corrective actions based on findings. The Medical Review Subject Matter Expert position would be responsible to provide expert clinical guidance and technical assistance, ensuring adherence to the medical review function of the PERM Program.

The candidate in this position ideally brings combination of program management experience and subject matter expertise in medical records review of the Medicaid and Children’s Health Insurance Program claims. The position is responsible for the advising on the business and operational processes to ensure the full optimal medical review function to ensure timely and quality deliver of PERM program.

**_Hybrid or full-time remote work. This is position is contingent on contract award._**

**In this role, you will:**

+ Be in direct communication with the Assistant Program Director for Medical Claims, Medical Review Manager, Medical Reviewers, and the CMS PERM staff to provide expert clinical guidance and technical assistance, ensuring adherence to the medical review function

+ Provide guidance and oversight support on the medical review protocol necessary for timely, full and complete review of medical records received to ensure completion and quality medical review to meet requirements of the PERM program.

+ Identify updates on medical review protocols and improvements to streamline and automate review processing to enhance program efficiency and coordination.

**Competencies**

+ Extensive knowledge and proven ability to continually assesses and evaluate clinical compliance with relevant regulations, both at a state and federal level.

+ Extensive knowledge of state and federal healthcare regulations, policies, coverage guidelines, and reimbursement rules

+ Extensive experience in making clinical determinations as to the medical necessity and appropriateness of services rendered and billed and corresponding payment determinations;

+ Extensive knowledge of the Medicaid and/or CHIP program, particularly the coverage, conditions of payment, and state-specific policy requirements for health care coverage and payment;

+ Experience with process improvements of medical review and medical coding review protocols

+ An analytical mindset with problem-solving abilities.

+ Strong leadership and organizational skills.

+ Excellent communication skills, both strong orally and written skills.

+ Exceptional interpersonal skills with ability toestablish and maintain effective working relationships.

+ Enjoy working in fast-paced and collaborative team environment.

**Qualifications**

The Medical Review Subject Matter Expert will possess a combination of experience meeting the following criteria:

+ A minimum of three (3) years’ experience practicing nursing as a licensed Registered Nurse;

+ A minimum of three (3) years’ experience in a supervisory/managerial role in the health insurance industry, a utilization review firm, or another health care claims processing organization involving medical and coding reviews of a variety of medical and surgical claims from a variety of provider types;

+ Extensive experience performing medical review and/or utilization/QA reviews;

+ Education, Licensure, and Certification:

+ Hold a Bachelor’s Degree in Nursing

+ Current Registered Nurse Licensure

+ CPC Certification

If you are interested in supporting our mission and working with a passionate team - then submit your application now for immediate consideration. It only takes a few minutes and could change your career!

**Company Overview**

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. While your place may look a little different depending on your role, we know you will find yours here. 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.

To review Serco benefits please visit: . If you require an accommodation with the application process please email: or call the HR Service Desk at , option 1. Please note, due to EEOC/OFCCP compliance, Serco is unable to accept resumes by email.

Candidates may be asked to present proof of identify during the selection process. If requested, this will require presentation of a government-issued I.D. (with photo) with name and address that match the information entered on the application. Serco will not take possession of or retain/store the information provided as proof of identity. For more information on how Serco uses your information, please see ourApplicant Privacy Policy and Notice ( .

Serco does not accept unsolicited resumes through or from search firms or staffing agencies without being a contracted approved vendor. All unsolicited resumes will be considered the property of Serco and will not be obligated to pay a placement or contract fee. If you are interested in becoming an approved vendor at Serco, please email .

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.

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**ID** _64343_

**Recruiting Location : Location** _US-DC-_

**Category** _Health/Medical_

**Position Type** _Full-Time_

**Security Clearance** _None_

**Telework** _Yes - May Consider Full Time Teleworking for this position_