Medical Review Nurse – Medicare

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

📋 Description

• Perform reviews of medical records and utilize sound clinical judgment for claims payment determinations.

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

• Analyze complex data model outputs.

• Utilize tools to identify potential fraud and assist in ongoing fraud investigations and information requests.

• Identify and formulate cases for future administrative actions, including referrals to law enforcement, education initiatives, and overpayment recovery.

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

• Address requests for data and provide support.

• Highlight issues of concern, referencing regulatory violations and alleging schemes designed to defraud the Government.

• Research regulations and note violations.

• Conduct independent research to identify issues in Medicare payments to both institutional and non-institutional providers.

• Make claims payment decisions rooted in clinical expertise.

• Draft correspondence, reports, and referral summary letters.

• Timely report work activities.

• Participate in meetings, training sessions, and conferences.

• May be required to testify in court regarding work findings.

⛳️ Requirements

• A minimum of 5 years of experience with a BS/BA or 7 years with an Associate's degree.

• Professional experience 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.

• Demonstrated strong investigative skills.

• Excellent communication and organizational skills.

• Proficient PC knowledge and skills.

• US citizenship is mandatory.

• Experience in reviewing claims for technical requirements, conducting medical reviews, and/or developing fraud cases (candidates with this experience will be most competitive).

• CPC (Certified Professional Coder) certification preferred (most competitive candidates).

• Capability to appear in court and testify regarding work findings.

• Proficient in composing correspondence, reports, and referral summary letters.

• Ability to communicate effectively with both internal and external stakeholders.

• Capacity to manage confidential information responsibly.

• Timely reporting of work activities is essential.

• Ability to work autonomously as well as collaboratively within a team.

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

• Overnight travel may be required.

🏝️ Benefits

• Medical insurance coverage.

• Dental insurance coverage.

• Vision insurance coverage.

• Life insurance coverage.

• Health savings account (HSA) options.

• Short-term disability insurance.

• Long-term disability insurance.

• Employee assistance program (EAP) access.

• Parental leave benefits.

• 401(k) retirement plan.

• Paid time off (PTO) for vacations.

• Company-paid holidays.

• Potential eligibility for overtime pay.

• Potential eligibility for shift differentials.

• Potential eligibility for discretionary bonuses.