Seeking Registered Nurse for fully remote role to perform complex medical record and claim reviews (Standard or Program Integrity) to make coverage determinations based on applicable Medicare coverage policies and payment rules, coding guidelines, National and Local Coverage Determinations, utilization/practice guidelines, clinical review judgment and when appropriate, monitor for potential indicators of fraud, waste, and abuse. Provides professional assessment, planning, coordination, implementation, and reporting of complex data to support the Medical Review Accuracy Contract (MRAC). Essential Functions Perform complex medical record and claims review in accordance with all State and Federal mandated regulations/guidelines. Accurately enter medical review data into the medical review system. Apply clinical review judgment, based on clinical experience when applicable and review completeness of documentation to determine if documentation supports claim as billed. Reasonably determines appropriateness to consult a Subject Matter Expert (SME) for clarification. When performing Program Integrity (PI) reviews, assess investigative allegations and medical review findings, and/or other claims data to determine patterns and detect potential indicators of fraud, waste and abuse (FWA). Accurately identify additional findings in the review of evidence of potential FWA not detected by the Medical Review Contractor. Consistently meet or exceed productivity and accuracy standards of 98% minimum IRR established by the customer and/or the Company.

Required Qualifications

A Registered Nurse, with a current unobstructed license to practice nursing in the United States. Graduate of a Board approved Registered Nursing program. A minimum of three (3) or more years’ experience in medical record review with Medicare Part A and Part B. Minimum of 2 (two) years’ experience in the medical review processes of MACs, SMRC, CERT, QICs and/or BFCC-QIOs. A minimum of five (5) years clinical experience in an acute care hospital, skilled nursing facility, and/or an office/clinic-based medical practice Required Skills & Abilities Working experience with electronic medical records or electronic transmission of medical records. Knowledge of ICD-9-CM, ICD-10, CPT-4 and HCPCS coding. Expertise in Medicare Part A policy, including inpatient hospital and other facility claims. Expertise in Medicare Part B policy, including outpatient and other physician services and durable medical equipment. Ability to work independently and maintain an elevated level of concentration. Capable of consistency, speed, and accuracy of task. Ability to read, analyze, and interpret physician documentation. Proficiency in research, interpretation, and application of, Medicare, Medicaid, and local healthcare regulations and policies. Self-motivated, well-organized, and detail oriented.

Preferred Qualifications

A Bachelor’s Degree in Nursing (BSN) or other related field. Certification in coding. Experience performing medical review for fraud, waste, and abuse (FWA) investigations. One year or more of utilizing InterQual and/or Milliman guidelines against inpatient services experience. Requirements for Federal Contract Staffing Eligibility for federal background checks, including residence in the United States for at least 3 years out of the past 5 years