Medical Review Nurse – Medicare

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

📋 Description

• Perform reviews of medical records while applying sound clinical judgment to decisions regarding claim payments.

• Investigate medical claims data along with other information sources to pinpoint issues.

• Analyze outputs from complex data models.

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

• Recognize and compile cases for potential administrative actions, which may include referrals to law enforcement, educational outreach, and recovery of overpayments.

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

• Address requests for data and provide support.

• Highlight issues of concern, referencing regulatory breaches and alleging schemes or scams aimed at defrauding the Government.

• Investigate regulations and document violations.

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

• Make decisions on claim payments grounded in clinical expertise.

⛳️ Requirements

• Minimum of 5 years of experience with a BS/BA degree.

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

• Active nursing license.

• Exceptional investigative abilities.

• Strong communication and organizational skills.

• Proficient PC skills and knowledge.

• U.S. citizenship is mandatory.

• Experience in assessing claims for technical compliance, conducting medical reviews, and/or developing fraud cases.

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

• Capability to testify in court regarding findings from work.

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

• Effective communication skills for both internal and external interactions.

• Ability 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.

• Availability for overnight travel is required.

🏝️ Benefits

• Medical insurance.

• Dental insurance.

• Vision insurance.

• Life insurance.

• Health savings account.

• Short-term disability.

• Long-term disability.

• Employee assistance program (EAP).

• Parental leave.

• 401(k) plan.

• Paid time off (PTO) for vacation.

• Company-paid holidays.

• Eligibility for overtime.

• Eligibility for shift differentials.

• Eligibility for discretionary bonuses.