Medical Policy Review Nurse

This is a fully remote position, open to applicants in United States.

📋 Description

• Assess CPT, HCPCS Level II, ICD-10-CM/PCS, MS-DRG, revenue, and various codes against clinical evidence, benefit parameters, medical policies, and regulatory guidelines.

• Collaborate with Medical Directors, Utilization Management personnel, coding and compliance teams, product teams, and policy analysts.

• Conduct code validations and pinpoint incorrect or inconsistent usage.

• Propose prior authorization prerequisites.

• Assist with audits and provide guidance on emerging procedures, technologies, and regulatory updates.

• Utilize coding standards, clinical literature, CMS NCDs/LCDs, medical necessity principles, and utilization management criteria.

• Create evidence-based recommendations for coverage, authorization, and coding treatments.

• Facilitate accurate, clinically supported coverage determinations, coding integrity, claims integrity, and federal healthcare mission outcomes.

⛳️ Requirements

• An Associate degree in Nursing is required; a bachelor’s degree is preferred.

• Registered Nurse with proven experience in medical coding, medical policy, utilization management, claims, reimbursement, or clinical documentation review.

• Over 5 years of related experience.

• Familiarity with CPT, HCPCS Level II, ICD-10-CM, ICD-10-PCS, revenue codes, modifiers, Place of Service codes, NCCI edits, medical necessity standards, prior authorization processes, and benefit/coverage concepts.

• CPC, CCS, CCA, CRC, or equivalent certification is preferred.

• MBI (T2) public trust requirement.

• Competence in conducting detailed clinical coding reviews.

• Ability to assess medical documentation and investigate complex clinical/coding topics.

• Skill in interpreting medical policies and collaborating across clinical, operational, and coding teams.

• Prior supervisory and/or team management experience is essential.

• Willingness to travel less than 10% as required.

• US citizenship is not mandatory.

🏝️ Benefits

• Comprehensive medical plan options, including those with Health Savings Accounts.

• Dental plan options available.

• Vision plan options available.

• 401(k) plan with company matching.

• Flexible work weeks.

• Vacation, sick, personal, holiday, paid parental, military, bereavement, and jury duty leave.

• Typically, 15 days of paid leave per calendar year.

• 10 paid holidays each year.

• Up to 160 hours of paid family leave in a rolling 12-month period for eligible employees.

• Short- and long-term disability benefits.

• Life insurance coverage.

• Accidental death and dismemberment insurance.

• Personal accident insurance.

• Critical illness insurance.

• Business travel and accident insurance.

• AI-driven career tool to identify career advancement steps and learning opportunities.

• Internal mobility team dedicated to supporting career aspirations.

• An award-winning culture of innovation.

• A military-friendly workplace.