Medical Review Nurse at 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.
- 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.
- 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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