Job Description

Position Overview:
We are seeking a Registered Nurse for a fully remote role specializing in complex medical record and claim reviews. In this position, you will make coverage determinations based on Medicare policies, coding guidelines, and clinical judgment, while also monitoring for potential indicators of fraud, waste, and abuse. This role plays a critical part in supporting the Medical Review Accuracy Contract (MRAC) through professional assessment, coordination, and reporting of complex data.

Key Responsibilities:

Conduct complex medical record and claims reviews in compliance with State and Federal regulations.
Enter medical review data accurately into the designated system.
Utilize clinical review judgment to assess documentation completeness and support claims as billed.
Identify opportunities to consult with Subject Matter Experts (SMEs) for clarification as needed.
Conduct Program Integrity (PI) reviews to detect patterns and potential indicators of fraud, waste, and abuse (FWA).
Identify additional findings related to potential FWA not initially detected.
Maintain productivity and accuracy standards, meeting or exceeding minimum IRR of 98% set by stakeholders.
Requirements:

Registered Nurse with current, unobstructed licensure to practice nursing in the United States; graduate of a Board-approved Registered Nursing program.
Bachelor's Degree in Nursing (BSN) or related field preferred.
Certification in coding highly desired.
Minimum of five (5) years clinical experience in acute care hospital, skilled nursing facility, or office/clinic-based medical practice.
Three (3) or more years' experience in medical/utilization medical record review, particularly with Medicare and/or Medicaid.
Two (2) or more years' experience in medical review processes of MACs, SMRC, CERT, QICs, and/or BFCC-QIOs.
Experience performing medical reviews for fraud, waste, and abuse (FWA) investigations preferred.
Proficient in ICD-9-CM, ICD-10, CPT-4, and HCPCS coding.
Familiarity with InterQual and/or Milliman guidelines for inpatient services preferred.
Benefits:

Comprehensive Benefit Package including:
Paid time off for Holidays, Sick Leave, and Vacation.
Medical, Dental, Vision, and Life Insurance.
401K with Employer Match upon eligibility.
Employment Type: Full-Time
Salary: $ 35.00 Per Hour

Job Tags

Hourly pay, Holiday work, Full time, Contract work, Remote job,

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