Nurse Reviewer – Medicare

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

📋 Description

• Conduct detailed medical record evaluations that require clinical judgment for Medicare Part A/B and DMEPOS claims.

• Assess coverage, medical necessity, and the suitability of services in accordance with NCDs, LCDs, and CMS coverage/payment policies.

• Provide a clear and defensible rationale for recommendations regarding payment or denial.

• Detect signs of medical record alterations or documentation trends indicative of fraud, waste, or abuse.

• Engage in provider education sessions and articulate review rationales directly to providers and suppliers.

• Assist with claim re-evaluations when supplementary documentation is provided.

• Achieve and maintain an individual accuracy score of 95% or higher while participating in inter-rater reliability and peer-review quality assurance activities.

• Fulfill mandatory annual training requirements and uphold HIPAA/PHI compliance.

⛳️ Requirements

• Graduation from an accredited nursing program.

• Current and unrestricted Registered Nurse (RN) license; an active compact multistate RN license is acceptable.

• License must be recognized in the relevant jurisdiction(s) for assigned duties.

• For federal contract positions, the license must be issued by a recognized body within the United States.

• 2–4 years of clinical experience.

• Capability to apply clinical judgment in determining medical necessity, coverage, and appropriateness of care according to NCDs, LCDs, and CMS coverage policies.

• Strong understanding of medical terminology and standards for clinical documentation.

• Associate's degree or an accredited nursing diploma in a healthcare-related discipline, complemented by a professional clinical background.

• Experience in medical/claims review, including both pre- and post-payment claims assessments and/or utilization reviews.

• Preferred experience in MAC or RAC appeals review.

• Preferred certification in CPC or a similar coding credential.

• Desired prior experience as a Medicare medical review nurse for a MAC, RAC, QIO, or SMRC-type contractor.

• Preferred experience in the insurance industry.

• Ability to sit, read, use a computer, and view a computer screen for prolonged periods.

• Ability to occasionally stand, walk, use hands and fingers, kneel, or crouch.

🏝️ Benefits

• Fully remote work opportunity.

• Reasonable accommodations available for individuals with disabilities.

• Equal employment opportunity with merit-based personnel processes.