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Job description
Position Description & Qualifications
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. Supporting CMS’s obligations under the Payment Integrity Information Act (PIIA), the program uses statistically valid sampling and independent medical review of claims to identify improper payments and measure program performance. 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 CERT
Participates 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 (preferred) with active state licensure
OR Graduate from an accredited Registered Nurse (RN) school (associate degree or diploma based)
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. Ø Good organizational skills Ø Knowledge of Microsoft office programs and databases
Additional desired qualifications:
A minimum of 4 years of clinical experience in medical or surgical nursing home (some of those years may be as an LPN)
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.
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.
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.
Pay Transparency
Our Total Rewards package includes competitive pay, performance-based incentives, and benefits that promote well-being and work-life balance—so you can thrive both professionally and personally. Eligible employees also gain access to a wide range of benefits from comprehensive health coverage and health savings accounts to retirement plans, life and disability insurance, and time-off programs that support work-life balance. Program availability may vary based on factors such as contract type, location, hire date, and applicable collective bargaining agreements.
Salary range: The range for this position can be found at the top of this posting. This range is provided as a general guideline and represents a good faith estimate across all experience levels. Actual base salary will be determined by a variety of factors, including but not limited to, the scope of the role, relevant experience, job-related knowledge, education and training, key skills, and geographic market considerations. For roles available in multiple states, the range may vary to reflect differences in local labor markets. In addition to base salary, eligible positions may include other forms of compensation such as annual bonuses or long-term incentive opportunities.
Benefits – Comprehensible benefits for full-time employees (part-time employees receive a limited package tailored to their role):
Medical, dental, and vision insurance
Robust vacation and sick leave benefits, and flexible work arrangements where permitted by role or contract
401(k) plan that includes employer matching funds
Tuition reimbursement program
Life insurance and disability coverage
Optional coverages that can be purchased, including pet insurance, home and auto insurance, additional life and accident insurance, critical illness insurance, group legal, ID theft protection
Birth, adoption, parental leave benefits
Employee Assistance Plan
To review all Serco benefits please visit: .
Serco complies with all applicable state and local leave laws, including providing time off under the Colorado Healthy Families and Workplaces Act for eligible Colorado residents, in alignment with our policies and benefit plans. The application window for this position is for no more than 60 days. We encourage candidates to apply promptly after the posting date, as the position may close earlier if filled or if the application volume exceeds expectations.
If an applicant has any concerns with job posting compliance, please send an email to: .
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Worksite address
carson city, NV, 89702, US
Who can apply
Review the original listing for work authorization, qualifications and employer requirements.