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Medical Review Nurse

Avenue Code, LLC

Remote • 6d ago

Easy Apply

Full-time

80,000 - 90000

Clinical Medical Review Nurse

Charter Global, Inc.

Remote • 20d ago

Easy Apply

Contract, Third Party

Depends on Experience

Clinical Review Nurse

nTech Solutions

Hybrid in Baltimore, Maryland • 17d ago

Easy Apply

Contract

$40+

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 30+ days ago

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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 30+ days ago

Fitment

Dice Job Match Score™

To see how well you match this job, please log in or create an account.

Once logged in, be sure to complete your profile to get the most accurate match score.

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