Medical Review Nurse

Seeking Registered Nurse for fully remote role to perform complex medical record and claim reviews for various services and equipment (Medicare Part A and Part

B) to make coverage determinations based on applicable Medicare coverage policies and payment rules, coding guidelines, National and Local Coverage Determinations, utilization/practice guidelines, clinical review judgment and when appropriate, monitor for potential indicators of fraud, waste, and abuse. Provides professional assessment, planning, coordination, implementation, and reporting of complex data to support the AI Medical Review Contract (AI MRR).Essential Functions Review of Medicare Fee-for-Service payment policies for various services and equipment covered in Medicare Part A and Part BReview of medical documentation for Medicare Fee-for-Service claims for various services and equipment covered in Medicare Part A and Part BE valuation of the accuracy of an AI-assisted process to translate policy documents into structured rules for determining compliance with Medicare policy

Evaluation of the accuracy of the determinations of an AI-assisted tool in recommending determinations of compliance with Medicare policy

Evaluating the ease of integrating an AI-assisted tool into claim review processes

Support the Program Manager and technical teams in meeting deliverable schedules

When performing Program Integrity (PI) reviews, assess investigative allegations and medical review findings, and/or other claims data to determine patterns and detect potential indicators of fraud, waste and abuse (FWA)
Consistently meet or exceed productivity and accuracy standards of 98% minimum IRR established by the customer and/or the Company.

Required Qualifications A Registered Nurse, with a current unobstructed license to practice nursing in the United States. Graduate of a Board approved Registered Nursing program.

A minimum of three (3) or more years’ experience in medical record review with Medicare Part A and Part

B.Minimum of 2 (two) years’ experience in the medical review processes of MACs, SMRC, CERT, QICs and/or BFCC-QIOs.A minimum of five (5) years clinical experience in an acute care hospital, skilled nursing facility, and/or an office/clinic-based medical practic

Required Skills & Abilities

Working experience with electronic medical records or electronic transmission of medical records.

Knowledge of ICD-9-CM, ICD-10, CPT-4 and HCPCS coding.

Expertise in Medicare Part A policy, including inpatient hospital and other facility claims.

Expertise in Medicare Part B policy, including outpatient and other physician services and durable medical equipment.

Ability to work independently and maintain an elevated level of concentration.

Capable of consistency, speed, and accuracy of task.

Ability to read, analyze, and interpret physician documentation.

Proficiency in research, interpretation, and application of, Medicare, Medicaid, and local healthcare regulations and policies.

Self-motivated, well-organized, and detail oriented.

Preferred Qualifications A Bachelor’s Degree in Nursing (BSN) or other related field.

Certification in coding.

Experience performing medical review for fraud, waste, and abuse (FWA) investigations.

One year or more of utilizing Inter Qual and/or Milliman guidelines against inpatient services experience.

Requirements for Federal Contract Staffing Eligibility for federal background checks, including residence in the United States for at least 3 years out of the past 5 years