Medical Review Specialist DME

1 month ago

Manila, Philippines Med Supply US Full time ₱30,000 - ₱35,000
Med Supply US is one of the nation's leading home medical supply companies with years of experience serving patients with complex medical needs. We offer a full scope of Continuous Glucose Monitors (CGMs) and other diabetes products and services. We have built a collaborative culture that has allowed us to hire the best and deliver a world-class experience for our patients. If you enjoy working in a high-energy, employee-friendly environment where you get to play an active role in the success of the organization, we may be just the company for you.

Job Summary:
The DME Medical Review Specialist plays a critical role in the healthcare industry by ensuring the appropriate utilization and billing of Durable Medical Equipment. This position involves reviewing medical documentation and claims to assess the medical necessity, compliance with regulations, and accuracy of DME services and equipment provided to patients. The DME Medical Review Specialist contributes to efficient healthcare delivery, cost containment, and adherence to regulatory guidelines.

Key Responsibilities:

  • Medical Documentation Review: Analyze medical records, physician notes, and supporting documentation to determine the medical necessity of DME services and equipment.
  • Claims Evaluation: Review insurance claims and billing documents to verify accuracy, completeness, and compliance with coding and billing guidelines.
  • Utilization Review: Assess the appropriateness of DME services based on established clinical criteria and guidelines to ensure patients receive the most suitable equipment for their medical needs.
  • Regulatory Compliance: Stay current with Medicare, Medicaid, and private insurance regulations related to DME, ensuring all services and equipment adhere to established guidelines.
  • Communication: Collaborate with healthcare providers, insurance companies, and patients to obtain additional information or clarification regarding DME orders and claims.
  • Documentation: Maintain detailed records of reviews, findings, and actions taken, ensuring all documentation is accurate and compliant with regulations.
  • Quality Improvement: Identify trends, issues, and areas for improvement in DME utilization and billing, and provide recommendations for process enhancements.
  • Training and Education: Assist in the development and delivery of training programs to educate healthcare providers, staff, and stakeholders on DME regulatory requirements and best practices.
  • Auditing: Conduct internal and external audits to assess the accuracy and compliance of DME claims, documentation, and billing procedures.
  • Reporting: Prepare reports summarizing review outcomes, discrepancies, and compliance issues, and communicate these findings to relevant parties.
  • Data Analysis: Utilize data analytics tools and software to analyze trends in DME utilization and identify potential areas of concern.
  • Customer Service: Provide assistance and guidance to patients and healthcare providers regarding DME inquiries, claims, and appeals processes.

Qualifications:

  • Bachelor's degree in a related healthcare field (e.g., Nursing, Health Information Management) or equivalent relevant experience.
  • Knowledge of Durable Medical Equipment, Medicare, Medicaid, and private insurance regulations and guidelines.
  • Strong understanding of medical terminology, coding, and billing procedures.
  • Analytical skills and attention to detail.
  • Excellent written and verbal communication skills.
  • Ability to work independently and as part of a team.
  • Proficiency in using computer software and databases for documentation and analysis.

Experience:

  • Prior experience in healthcare reimbursement, medical coding, or medical billing is preferred.
  • Familiarity with auditing and quality improvement processes is an advantage.
  • Knowledge of electronic health records (EHR) and healthcare information systems is beneficial.

The DME Medical Review Specialist plays a pivotal role in upholding the integrity of DME services, ensuring patient access to necessary equipment, and minimizing fraudulent or improper billing practices. This position requires a deep understanding of medical regulations and a commitment to maintaining the highest standards of patient care and compliance.

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