Medical Review Nurse – Commercial DME Auditor

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

📋 Description

• Conduct audits on claims to ensure services are medically appropriate in both inpatient and outpatient environments, utilizing medical review guidelines, policies, and regulations.

• Record audit results with references to relevant policies and regulations.

• Create letters that detail the findings of the audit.

• Provide support for audit outcomes during the appeals process as needed.

• Work collaboratively with the audit team to identify and secure approval for vulnerabilities or potential cases of abuse.

• Collaborate with clients, CMD colleagues, and contractors to enhance medical policies, provider education, and system edits.

• Keep informed about changes in medical practices, technology, and regulatory matters that impact clients.

• Assist in reducing appeals, enhancing audit workflows, contributing to QA functions, and training team members.

• Engage in the establishment of edit parameters, new issue packets, and Medical Review Guidelines.

• Interface with and provide support to the Medical Director.

• Participate in cross-training across clinical departments and areas.

• Execute additional duties as necessary to fulfill business requirements.

⛳️ Requirements

• A current, unrestricted RN license in good standing is mandatory.

• Must not be currently sanctioned or excluded from the Medicare program by the OIG.

• At least five (5) years of diverse nursing experience providing direct care in either inpatient or outpatient settings.

• A minimum of one (1) year of experience in conducting medical records reviews.

• At least one (1) year of experience in health care claims with proficiency in ICD-9/ICD-10 coding, HCPCS/CPT coding, DRG, and medical billing for an insurance company or hospital.

• Familiarity with utilization management systems or clinical decision-making tools such as MCG or InterQual.

• Extensive knowledge of ICD-9, ICD-10, CPT-4, or HCPCS coding.

• Understanding of insurance programs, particularly regarding coverage and payment regulations.

• Capability to sustain high-quality work while adhering to strict deadlines.

• Exceptional written and verbal communication skills.

• Ability to manage various tasks, including desk audits and claims reviews.

• Proficiency in independently utilizing standard office computer technology and case management systems/tools.

• Skill in managing multiple assignments, documenting findings and recommendations, and organizing and prioritizing workload.

• Ability to work independently as well as collaboratively in a remote environment.

• Strong preference for experience in performing utilization review for an insurance organization, Tricare, MAC, or a similar entity.

🏝️ Benefits

• Flexible remote work arrangement.

• Commitment to equal employment opportunity.

• Provision of reasonable accommodations during the application or recruitment process.

• Employment is at will.