Nurse Reviewer - Tampa, FL
$83,200–$83,200 year
Remote · United States
Job Summary
Nurse Reviewer conducts medical necessity and policy reviews for Medicaid claims, performing comprehensive medical record reviews, end-to-end case screening, and documentation of evidence-based criteria. Roles include evaluating claims with ICD-10, CPT, and HCPCS codes, maintaining knowledge of evolving Medicaid policies, meeting productivity and quality standards, and collaborating with the Team Lead, Physician Peer Reviewer, and contract team. Remote, part-time position (20-30 hours/week) requiring BSN with active RN licensure and several years of medical record review experience; proficient in Word/Excel/Outlook and Adobe PDF; HIPAA/HITECH compliance is required.
Required Qualifications
- BSN with active RN licensure in good standing
- At least three to five years performing medical record review and/or abstraction (Utilization Review experience preferred)
- Experience performing medical record review, audit for federal or state contracts
- Knowledge and experience of Medicare and Medicaid policy
- Proficiency with Microsoft Office (Word, Excel, and Outlook)
- Proficiency with Adobe PDF files and features
- Current experience (within the last 3 years) in the application of clinical screening criteria (InterQual and MCG)
- Professional interpersonal skills; ability to interact with providers, physicians and peers
- Solid analytical, assessment and documentation skills
- Effective written and verbal communication, both internally and externally
- Strong attention to detail
- Strong attention to deadlines
- Organizational skills including effective time management, priority setting and process improvement
- Ability to work independently and as a member of a team
- Adapt to changing work situations and readily adjusts schedules, tasks and priorities when necessary to meet business fluctuations
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