Nurse Reviewer

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

📋 Description

• Perform evaluations of medical records and utilize sound clinical judgment for claim payment decisions.

• Investigate medical claims data and additional information to pinpoint issues.

• Analyze complex data model outputs.

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

• Identify and prepare cases for future administrative actions, such as law enforcement referrals, educational efforts, and recovery of overpayments.

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

• Address data requests and provide support as needed.

• Highlight concerns, referencing regulatory violations and alleging schemes or scams intended to defraud the Government.

• Investigate regulations and cite any violations discovered.

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

• Make claim payment determinations based on clinical expertise.

• Testify in court regarding findings when necessary.

• Draft correspondence, reports, and summary referral letters.

• Document work activities promptly.

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

⛳️ 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 another clinician, and/or experience in reviewing medical claims for coverage and medical necessity.

• Valid nursing license is required.

• Excellent investigative abilities.

• Strong communication and organizational skills.

• Proficient computer skills and knowledge.

• US citizenship is mandatory.

• Experience in reviewing claims for technical specifications, conducting medical reviews, and/or creating fraud cases.

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

• Capability to testify in court regarding findings.

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

• Effective internal and external communication skills.

• Proficient in handling confidential information.

• 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 is necessary.

🏝️ Benefits

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

• Overtime opportunities may exist.

• Shift differentials may be applicable.

• Discretionary bonuses may be offered.

• Commitment to equal opportunity employment, including protections for individuals with disabilities and veterans, as well as other legally protected characteristics.