Medical Review Nurse (AIMRR) 2
$76,875–$97,375 year
RemoteUnited States
Job Summary
Conduct complex medical record and claims reviews for Standard or Program Integrity to make coverage determinations based on Medicare policies, coding guidelines, and clinical judgment. Accurately enter review data into the medical review system and assess investigative allegations to detect potential indicators of fraud, waste, and abuse. Apply clinical review judgment to determine if documentation supports claims as billed, consulting Subject Matter Experts when necessary. Consistently meet or exceed productivity and accuracy standards of 98% minimum IRR while monitoring for additional findings not detected by the Medical Review Contractor. Requires a Registered Nurse with a current unobstructed US license, BSN preferred, and minimum five years clinical experience including three years in medical record review. Fully remote role with certification in coding highly preferred.
Required Qualifications
- Registered Nurse
- current unobstructed license to practice nursing in the United States
- Graduate of a Board approved Registered Nursing program
- minimum of five (5) years clinical experience in an acute care hospital, skilled nursing facility, and/or an office/clinic-based medical practice
- minimum of three (3) or more years' experience in medical/utilization medical record review particularly with Medicare and/or Medicaid
- Minimum of 2 (two) years' experience in the medical review processes of MACs, SMRC, CERT, QICs and/or BFCC-QIOs
Desired Qualifications
- Bachelor's Degree in Nursing (BSN) or other related field
- Certification in coding
- Desired experience performing medical review for fraud, waste, and abuse (FWA) investigations
- Knowledgeable of ICD-9-CM, ICD-10, CPT-4 and HCPCS coding
- One year or more of utilizing InterQual and/or Milliman guidelines against inpatient services experience
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