Nurse Reviewer

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

📋 Description

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

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

• Analyze complex data model outputs.

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

• Identify and prepare cases for future administrative actions, including 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 concerning issues by citing regulatory breaches and alleging schemes intended to defraud the Government.

• Investigate regulations and document any violations.

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

• Make payment decisions based on clinical expertise.

• Draft correspondence, reports, and summaries for referrals.

• Participate in meetings, training sessions, and conferences, with overnight travel required.

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

⛳️ Requirements

• 5 years of experience with a BS/BA; 3 years with an MS/MA; 0 years with a PhD.

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

• Valid nursing license is necessary.

• Exceptional investigative skills.

• Excellent communication and organizational abilities.

• Proficient knowledge and skills in PC usage.

• U.S. citizenship is mandatory.

• Experience in reviewing claims for technical compliance, conducting medical reviews, and/or developing fraud cases is highly competitive.

• CPC (Certified Professional Coder) certification is highly competitive.

• Capability to testify in court regarding findings from work.

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

• Ability to communicate effectively both internally and externally.

• Competence in managing confidential information.

• Timeliness in reporting work activities is essential.

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

🏝️ Benefits

• Telework options available from any location within the United States.

• Eligibility for overtime may be applicable.

• Shift differentials may be applicable.

• Potential for discretionary bonuses.

• Overnight travel is required for meetings, training sessions, and conferences.