Nurse Reviewer – Medicaid

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

📋 Description

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

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

• Analyze complex data model outputs.

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

• Develop and identify cases for future administrative actions, which may include referrals to law enforcement, educational initiatives, and recovery of overpayments.

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

• Highlight issues of concern by citing regulatory violations and alleging schemes or scams aimed at defrauding the Government.

• Investigate regulations and document violations.

• Conduct independent research to reveal problems in Medicaid payments to both institutional and non-institutional providers.

• Make claim payment determinations based on clinical expertise.

• Testify in court regarding findings, if necessary.

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

• Effectively communicate with both internal and external parties.

• Manage confidential information securely.

• Timely report work activities.

• Work autonomously and collaboratively within a team to produce high-quality outcomes.

• Attend meetings, training sessions, and conferences as required.

⛳️ Requirements

• A Bachelor's degree with 5 years of experience, a Master's degree with 3 years of experience, or an Associate's degree with 7 years of experience.

• Background 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 and active Nursing or Physical Therapy license in the state of residence.

• U.S. citizenship is mandatory.

• Excellent investigative abilities.

• Strong communication and organizational skills.

• Proficient knowledge and skills in using PCs.

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

• Familiarity with Medicaid requirements, laws, rules, and regulations governing payment for billed services.

• A CPC (Certified Professional Coder) certification is preferred.

🏝️ Benefits

• Telework options available for those in contiguous United States.

• Overnight travel may be necessary.

• Employees may qualify for overtime, shift differentials, and discretionary bonuses in addition to their base salary.

• Equal opportunity employer, inclusive of individuals with disabilities and protected veterans, along with other legally protected characteristics.