Senior Nurse Reviewer, Medicare

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

📋 Description

• Execute intricate reviews of medical records pertaining to Medicare Part A/B and DMEPOS claims.

• Evaluate potential instances of overpayment or fraud by applying established criteria and clinical guidelines.

• Make medical determinations concerning the validity of claims and payment levels in alignment with national and local policies, as well as accepted care standards.

• Manage and supervise the medical review operations of a team.

• Carry out quality review activities and create training resources.

• Promote continuous improvement through enhancements in processes.

• Perform the highest complexity and escalated clinical medical reviews, including cases that have been reassigned.

• Mentor and offer technical support to Nurse Reviewers and Certified Coders on complex clinical and coding claims.

• Lead or participate in inter-rater reliability and peer review quality assurance initiatives.

• Ensure adherence to the required monthly accuracy standard of over 95%.

• Develop and maintain medical review training materials along with the Quality Control assessment plan.

• Monitor accuracy and quality trends within the team, suggesting corrective measures and process enhancements to the Medical Review Manager.

• Assist in identifying vulnerabilities and conducting trend/root-cause analysis for Program Integrity reviews.

• Complete mandatory annual CMS training and uphold HIPAA/PHI compliance.

⛳️ Requirements

• Bachelor's degree in nursing or a related healthcare discipline.

• A valid, unrestricted RN license; a compact multistate RN license is acceptable.

• A minimum of 5 years of clinical experience.

• At least 3 years of experience in Medicare-related utilization review, medical review, or claims review.

• Proven experience in providing guidance, mentorship, or lead-level direction to other clinical reviewers (RN/LPN) and/or coding personnel.

• In-depth knowledge of Medicare coverage, coding, and payment regulations, including the application of NCD/LCD.

• Excellent analytical, written, and verbal communication abilities.

• Capacity to handle confidential and sensitive information with care.

• Prior experience as a senior/lead reviewer or equivalent to “Medical Reviewer III” on MAC, RAC, QIO, or SMRC-type contracts (preferred).

• Experience in participating in inter-rater reliability or peer review quality assurance programs (preferred).

• CPC or a similar coding certification (preferred).

• Experience in supporting case file preparation for Administrative Law Judge (ALJ) hearing participation (preferred).

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

• Completion of required annual CMS trainings.

• Compliance with HIPAA/PHI regulations.

🏝️ Benefits

• Fully remote work arrangement.

• Reasonable accommodations for individuals with disabilities.

• Equal employment opportunity and nondiscrimination.