Nurse Reviewer - Sarasota, FL
$83,200–$83,200 year
Remote · Sarasota, Florida, United States
Job Summary
Nurse Reviewer (Part-Time, 20-30 hrs/wk, Remote) conducts comprehensive medical record reviews to determine medical necessity and compliance with Medicaid policies, preparing documentation and reporting results. Responsibilities include end-to-end case screening, recording evidence-based criteria for contract requirements, analyzing medical claims using ICD-10, CPT, and HCPCS codes, maintaining up-to-date knowledge of multi-state Medicaid policies, and collaborating with the Team Lead and Physician Peer Reviewer to meet productivity and quality standards. Requires RN licensure with a BSN and 3-5 years of medical record review or utilization review experience; proficiency in Microsoft Office and Adobe PDF; strong analytical, organizational, and communication skills; ability to work independently and in a team, with a focus on timely, accurate documentation and adherence to HIPAA/HITECH regulations.
Required Qualifications
- BSN with active RN licensure in good standing
- 3-5 years experience performing medical record review and/or abstraction (Utilization Review experience preferred)
- Experience reviewing medical records and auditing federal or state contracts
- Knowledge of Medicare and Medicaid policy
- Proficiency with Microsoft Office (Word, Excel, Outlook)
- Proficiency with Adobe PDF tools
- Knowledge of ICD-10, CPT and HCPCS codes
- Experience applying clinical screening criteria (InterQual and MCG)
- Strong written and verbal communication skills
- Ability to work independently and as part of a team
- Strong attention to detail and deadlines
- Experience complying with HIPAA/HITECH laws
- Educational background in nursing (BSN)
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