Medical Review Nurse – Medicare

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

📋 Description

• Perform reviews of medical records and utilize clinical expertise to make decisions on claim payments.

• Investigate medical claims data and other relevant information to pinpoint issues.

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

• Assist in ongoing fraud investigations and respond to information requests.

• Identify and build cases for administrative actions, including referrals to law enforcement, educational initiatives, and recovery of overpayments.

• Collaborate with external agencies to formulate cases and corrective measures.

• Address requests for data and provide necessary support.

• Highlight issues of concern by referencing regulatory breaches and alleging fraudulent schemes against the Government.

• Investigate regulations and document violations.

• Conduct independent research on Medicare payments to both institutional and non-institutional providers.

• Testify in court regarding work findings when necessary.

⛳️ Requirements

• 5 years of experience with a Bachelor’s degree, 3 years with a Master’s degree, or 7 years with an Associate’s degree.

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

• Current nursing license; must hold an active license in the US.

• Proficient investigative skills.

• Excellent communication and organizational abilities.

• Strong knowledge and skills in using PCs.

• US citizenship is mandatory.

• Capability to testify in court regarding work findings.

• Ability to draft correspondence, reports, and summary referral letters.

• Competence in managing confidential information.

• Timely reporting of work activities is essential.

• Ability to work autonomously and as part of a team.

• Willingness to attend meetings, training sessions, and conferences.

• CPC (Certified Professional Coder) certification is a plus.

🏝️ Benefits

• Telework options available from any state.

• Overtime eligibility may be applicable.

• Shift differentials may be offered.

• A discretionary bonus could be available.

• Overnight travel is required.