Search Jobs | Dice.com

1 results (0 new)

Group by company

Medical Review Nurse

Avenue Code, LLC

Remote • Yesterday

Easy Apply

Full-time

80,000 - 90000

Job Details

Skills

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

Fitment

Dice Job Match Score™

🔢 Crunching numbers...

Create job alert

Never miss an opportunity! Create an alert based on the job you applied for.

Remote

•

7d ago

Fraud, Waste, and Abuse (FWA) Medical Record ReviewerCandidate from approved states ONLY: DC, MD, VA, PA, DE, WV, & NC Work Mode: First week or 2, onsite 5 days per week for collaboration purposes / training / meeting the team. Then mainly WFH with occasional meetings onsite when necessary. No expenses Paid for any Travel. Elite Technical is seeking a Fraud, Waste, and Abuse (FWA) Medical Record Reviewer! We are seeking an experienced healthcare fraud investigator and medical record reviewer wit

Easy Apply

Contract

40 - 45

Medical Record Audit Specialist - Behavioral Health

Remote

•

14d ago

Certified Medical Coder/Medical Record Audit Specialist - Behavioral HealthLocation: Fully Remote, with occasional travel to Downtown Indianapolis, IN (expenses covered)Job Summary:We are seeking a Certified Medical Coder/Medical Record Audit Specialist with strong Behavioral Health coding experience to support a state Medicaid program engagement. This role focuses on auditing medical records and claims documentation for coding accuracy and compliance, identifying billing and documentation issue

Easy Apply

Contract

Depends on Experience

RN Clinical Auditor - Behavioral Health

Remote

•

14d ago

RN Clinical Auditor - Behavioral HealthLocation: Fully Remote, with occasional travel to Downtown Indianapolis, IN (expenses covered)Job Summary:We are seeking a Registered Nurse Clinical Auditor with extensive Behavioral Health experience to support medical record reviews and billing compliance audits for the Indiana Health Coverage Programs (IHCP). This role evaluates quality of care, reviews medical records and program policies, identifies compliance issues, prepares audit documentation and r

Easy Apply

Contract

Depends on Experience

Specialty Physician Coder - remote in CA

Remote

•

2d ago

Title: Specialty Physician Coder Location: Remote (Must reside in California) Duration: 09/01/2026 to 12/31/2026 Hours per Week: 40 (8 hrs/day) Pay: $4.66/hr Job Description Summary: Job Summary: Under the direction of the Coding Compliance Manager, the Specialty Physician Coder plays a key role in reviewing and analyzing specialty coding and billing for charge processing. This role is responsible for reviewing and accurately coding office, hospital, and surgical/procedures for reimbursement and

Easy Apply

Contract

Job Details

Skills

Summary

Medical Review Nurse

Remote

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

Dice Id: 10383289
Position Id: 9074788
Posted 1 day ago

Fitment

Dice Job Match Score™

🔢 Crunching numbers...

Create job alert

Never miss an opportunity! Create an alert based on the job you applied for.

Remote

•

7d ago

Easy Apply

Contract

40 - 45

Medical Record Audit Specialist - Behavioral Health

Remote

•

14d ago

Easy Apply

Contract

Depends on Experience

RN Clinical Auditor - Behavioral Health

Remote

•

14d ago

Easy Apply

Contract

Depends on Experience

Specialty Physician Coder - remote in CA

Remote

•

2d ago

Easy Apply

Contract

Medical Review Nurse

Skills

Summary

Dice Job Match Score™

Similar Jobs

Medical Review Nurse

Job Details

Skills

Summary

Dice Job Match Score™

Similar Jobs