Seeking Registered Nurse for fully remote role to perform complex medical record and claim reviews for various services and equipment (Medicare Part A and Part B) 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 AI Medical Review Contract (AI MRR).
Essential Functions
- Review of Medicare Fee-for-Service payment policies for various services and equipment covered in Medicare Part A and Part B
- Review of medical documentation for Medicare Fee-for-Service claims for various services and equipment covered in Medicare Part A and Part B
- Evaluation of the accuracy of an AI-assisted process to translate policy documents into structured rules for determining compliance with Medicare policy
- Evaluation of the accuracy of the determinations of an AI-assisted tool in recommending determinations of compliance with Medicare policy
- Evaluating the ease of integrating an AI-assisted tool into claim review processes
- Support the Program Manager and technical teams in meeting deliverable schedules
- 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)
- Consistently meet or exceed productivity and accuracy standards of 98% minimum IRR established by the customer and/or the Company.
- Registered Nurse, with a current unobstructed license to practice nursing in the United States.
- Graduate of a Board approved Registered Nursing program.
- A Bachelor’s Degree in Nursing (BSN) or other related field is preferred.
- A minimum of three (3) or more years’ experience in medical/utilization medical record review particularly with Medicare and/or Medicaid.
- A minimum of three years of lead/supervisory experience in the health insurance industry, a utilization review firm, or another health care claims processing organization involving medical and coding reviews of a variety of medical and surgical claims from a variety of provider types.
- Minimum of 2 (two) years’ experience in the medical review processes (i.e. MACs, SMRC, CERT, QICs and/or BFCC-QIOs).
- Working experience with electronic medical records or electronic transmission of medical records.
- Desired experience performing medical review for fraud, waste, and abuse (FWA) investigations.
- Knowledgeable of ICD-9-CM, ICD-10, CPT-4 and HCPCS coding.
- One year or more of utilizing InterQual and/or Milliman guidelines preferred.