Medical Review Nurse – Medicaid

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

📋 Description

• Perform evaluations of medical records and utilize sound clinical judgment in making claim payment determinations.

• Investigate medical claims data and additional information to pinpoint issues.

• Analyze complex data model outputs and employ tools to uncover potential fraud.

• Assist with ongoing fraud investigations and fulfill information requests.

• Identify and formulate cases for administrative action, which may include referrals to law enforcement, educational initiatives, and recovery of overpayments.

• Collaborate with external agencies to build cases and implement corrective measures.

• Address data requests and provide support as needed.

• Highlight issues of concern by citing regulatory breaches and alleging schemes aimed at defrauding the Government.

• Investigate regulations and document violations.

• Conduct independent research into Medicaid payments to both institutional and non-institutional providers.

• Make claim payment determinations leveraging clinical expertise.

• Testify in court regarding work findings when necessary.

• Draft correspondence, reports, and summary letters for referrals.

• Timely report work activities.

• Participate in meetings, training sessions, and conferences, which may involve overnight travel.

⛳️ Requirements

• A minimum of 5 years of experience with a BS/BA, 3 years with an MS/MA, 7 years with an associate degree, or 9 years with a high school diploma.

• Background in the medical field as a Registered Nurse or another clinician, and/or experience in reviewing medical claims for coverage and medical necessity.

• A current nursing license is required.

• Active license within the United States.

• Excellent investigative abilities.

• Strong communication and organizational skills.

• Capability to apply Federal, State, and Managed Care Organization (MCO) regulations to claims being reviewed.

• Proficient knowledge and skills in PC usage.

• US citizenship is mandatory.

• Preferred: experience in reviewing claims for technical compliance, conducting medical reviews, and/or developing fraud cases.

• Preferred: experience with cases related to services provided for Medicaid.

• Preferred: CPC (Certified Professional Coder) certification.

🏝️ Benefits

• Telework options available.

• Employees may qualify for overtime compensation.

• Employees may be eligible for a shift differential.

• Employees may receive a discretionary bonus.

• An equal opportunity employer, inclusive of individuals with disabilities and protected veterans.