Medical Review Nurse – Medicare

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

📋 Description

• Perform evaluations of medical records and apply sound clinical judgment to make decisions regarding claim payments.

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

• Analyze complex data model outputs.

• Employ tools to identify potential fraud and assist with ongoing fraud investigations and information requests.

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

• Collaborate with external agencies to develop cases and corrective measures, and respond to data requests and support needs.

• Present issues of concern, referencing regulatory violations and alleging fraudulent schemes against the Government.

• Investigate regulations and cite any violations.

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

• Make payment decisions on claims based on clinical expertise.

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

• Communicate effectively with both internal and external stakeholders.

• Manage confidential information responsibly.

• Report work activities promptly.

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

• Testify in court regarding work findings when necessary.

⛳️ Requirements

• Minimum of 2 years of experience with a BS/BA, 4 years with an Associate's degree, or 6 years with a high school diploma or equivalent.

• Background 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 is required.

• Strong investigative abilities.

• Excellent communication and organizational skills.

• Proficient computer knowledge and skills.

• U.S. citizenship is mandatory.

• Experience in reviewing claims for technical compliance, performing medical reviews, and/or developing fraud cases is preferred for the most competitive candidates.

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

🏝️ Benefits

• Medical insurance.

• Dental insurance.

• Vision insurance.

• Life insurance.

• Health savings account.

• Short/long term disability coverage.

• Employee Assistance Program (EAP).

• Parental leave.

• 401(k) retirement plan.

• Paid time off (PTO) for vacation.

• Company-paid holidays.

• Eligibility for overtime pay.

• Eligibility for shift differentials.

• Eligibility for discretionary bonuses.