Nurse Reviewer – Medicaid

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

📋 Description

• Perform evaluations of medical records and utilize clinical judgment to make informed claim payment decisions.

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

• Analyze complex data model outputs and employ tools to identify possible fraudulent activities.

• Assist in ongoing fraud investigations and fulfill information requests.

• Identify and construct cases for administrative actions, which may include law enforcement referrals, educational initiatives, and recovery of overpayments.

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

• Address requests for data and provide necessary support.

• Highlight issues of concern and reference regulatory breaches related to suspected government fraud schemes.

• Engage in self-directed research regarding Medicaid payments to both institutional and non-institutional providers.

• Draft correspondence, reports, and referral summary letters.

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

• Document work activities promptly.

• Participate in meetings, training sessions, and conferences as necessary.

• Be prepared to travel overnight when needed.

⛳️ Requirements

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

• Minimum of 3 years of experience in the medical field as a Registered Nurse or other clinician, or experience in reviewing medical claims for coverage and medical necessity.

• Active Nursing or Physical Therapy license in the state of residence required.

• Excellent investigative skills.

• Proficient communication and organizational skills.

• Strong computer knowledge and skills.

• U.S. citizenship is mandatory.

• Preferred experience includes reviewing claims for technical requirements, conducting medical reviews, and/or developing fraud cases.

• Familiarity with Medicaid requirements, laws, rules, and regulations regarding service billing is preferred.

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

🏝️ Benefits

• Teleworking options available for employees in the contiguous United States.

• Employees may qualify for overtime pay.

• Eligibility for shift differentials may be available to employees.

• Employees might be entitled to a discretionary bonus.