Medical Review Nurse

Remote • Posted 1 day ago • Updated 1 day ago
Full Time
No Travel Required
Remote
$80,000 - 90000/yr
Fitment

Dice Job Match Score™

🔢 Crunching numbers...

Job Details

Skills

  • CMS

Summary

Medical Review Nurse
Remote
 
 
Seeking Registered Nurse for fully remote role to perform complex medical record and claim reviews (Standard or Program Integrity) to make coverage determinations based on applicable Medicare coverage policies and payment rules, coding guidelines, National and Local Coverage Determinations, utilization/practice guidelines, clinical review judgment and when appropriate, monitor for potential indicators of fraud, waste, and abuse. Provides professional assessment, planning, coordination, implementation, and reporting of complex data to support the Medical Review Accuracy Contract (MRAC).
Essential Functions
  • Perform complex medical record and claims review in accordance with all State and Federal mandated regulations/guidelines.
  • Accurately enter medical review data into the medical review system.
  • Apply clinical review judgment, based on clinical experience when applicable and review completeness of documentation to determine if documentation supports claim as billed.
  • Reasonably determines appropriateness to consult a Subject Matter Expert (SME) for clarification.  
  • When performing Program Integrity (PI) reviews, assess investigative allegations and medical review findings, and/or other claims data to determine patterns and detect potential indicators of fraud, waste and abuse (FWA).
  • Accurately identify additional findings in the review of evidence of potential FWA not detected by the Medical Review Contractor.
  • Consistently meet or exceed productivity and accuracy standards of 98% minimum
Requirements
  • Registered Nurse, with a current unobstructed license to practice nursing in the United States.    Graduate of a Board approved Registered Nursing program.  
  • A Bachelor’s Degree in Nursing (BSN) or other related field is preferred.
  • Certification in coding highly preferred.
  • A minimum of five (5) years clinical experience in an acute care hospital, skilled nursing facility, and/or an office/clinic-based medical practice.
  • A minimum of three (3) or more years’ experience in medical review for payment accuracy, particularly with Medicare Part A, Skilled Nursing Facility, and/or Home Health
  • Minimum of 2 (two) years’ experience in the medical review processes of MACs, SMRC, and/or UPICs.
  • Desired experience performing medical review for fraud, waste, and abuse (FWA) investigations.
  • Knowledgeable of ICD-9-CM, ICD-10, CPT-4 and HCPCS coding.
  • One year or more of utilizing InterQual and/or Milliman guidelines against inpatient services experience is preferred
Employers have access to artificial intelligence language tools (“AI”) that help generate and enhance job descriptions and AI may have been used to create this description. The position description has been reviewed for accuracy and Dice believes it to correctly reflect the job opportunity.
  • Dice Id: 10383289
  • Position Id: 9074788
  • Posted 1 day ago
Create job alert
Set job alertNever miss an opportunity! Create an alert based on the job you applied for.

Similar Jobs

Remote

7d ago

Easy Apply

Contract

40 - 45

Remote

14d ago

Easy Apply

Contract

Depends on Experience

Remote

14d ago

Easy Apply

Contract

Depends on Experience

Remote

2d ago

Easy Apply

Contract

46

Search all similar jobs