Medical Review Nurse at Performant Financial Corporation

Performant Financial Corporation

Medical Review Nurse – Remote

Job Code: 2019-50-4R-015

Location: Remote U.S. – Reports to San Angelo, TX Office

Status: Regular Full Time


The Medical Review Nurse performs medical claims audit reviews. As a MR Nurse, you will join a team of experienced medical auditors and coders performing retrospective and prepayment audits on claims for Government, and Commercial Payers. You will work in a fast paced and dynamic environment and be part of a multi-location team.

In this role, you will be responsible for:

  • Auditing claims for medically appropriate services provided in both inpatient and outpatient settings
  • Applying appropriate medical review guidelines, policies and rules
  • Documenting all findings referencing the appropriate policies and rules
  • Generating letters articulating audit findings
  • Supporting your findings during the appeals process if requested
  • Working collaboratively with the audit team to identify and obtain approval for particular vulnerabilities and/or cases subject to potential abuse
  • Work in partnership with our clients, CMD colleagues, and other contractors on improving medical policies, provider education, and system edits
  • Keep abreast of medical practice, changes in technology, and regulatory issues that may affect the our clients
  • Work with the team to minimize the number of appeals
  • Suggest ideas that may improve audit work flows
  • Assist with QA functions
  • Participate in establishing edit parameters
  • Participate in establishing new issue packets
  • Participate in development of Medical Review Guidelines
  • Assist with training team members
  • Interface with and support the Medical Director
  • Cross train in all clinical departments/areas
  • Other duties as required to meet business needs

Required Skills and Knowledge:

  • Strong preference for experience performing utilization review for an insurance company, Tricare, MAC or organizations performing similar functions
  • Experience with utilization management systems or clinical decision making tools such as Medical Coverage Guidelines (MCG) or InterQual.
  • Experience with ICD-9, ICD-10, CPT-4 or HCPCS coding.
  • Knowledge of insurance programs program, particularly the coverage and payment rules.
  • Ability to maintain high quality work while meeting strict deadlines.
  • Excellent written and verbal communication skills.
  • Not currently sanctioned or excluded from the Medicare program by the OIG.
  • Active unrestricted RN license in good standing.
  • Ability to manage multiple tasks including desk audits and claims review.
  • Must be able to independently use standard office computer technology (e.g. email telephone, copier, etc.) and have experience using a case management system/tools to review and document findings.
  • Must be able to manage multiple assignments effectively, create documentation outlining findings and/or documenting suggestions, organize and prioritize workload
  • Work independently and with team members effectively.

Physical Requirements:

  • Sit/stand/ walk/8-10hr/day
  • Lift/carry/push/pull under and over 10lbs occasionally
  • Keying frequency, handling, reaching, fine manipulation

Education and Experience:

  • Minimum of three years diversified nursing experience providing direct care in an inpatient or outpatient setting.
  • One or more years experience performing medical records review.
  • One or more years experience in health care claims that demonstrates expertise in, ICD-9/ICD-10 coding, HCPS/CPT coding, DRG and medical billing experience for an Insurance Company or hospital required.

Other Requirements:

  • Must submit to and pass background check.
  • Must be able to pass a criminal background check; must not have any felony convictions or specific misdemeanors.
  • Must submit to and pass drug screen.

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