Medical Review Nurse

Job Summary

To support the mission of delivering high-quality at-home care, the full-time remote Medical Review Nurse will ensure compliance with CMS regulations for surgical dressing orders, manage pre-bill controls, and lead audit and appeals processes.

Key responsibilities

• Interpret and operationalize LCD policies for surgical dressings and establish criteria for various product types
• Build and pilot a quality assurance process for surgical dressing claims, ensuring clinical completeness and billing correctness
• Lead responses to UPIC/MAC ADRs and coach the internal billing team while creating a reusable appeals library

Required qualifications

• 3-5+ years of medical review experience at a UPIC or MAC
• Hands-on experience with adjudication of surgical dressings and knowledge of proof of delivery standards
• Strong writing skills anchored in policy and ability to work under deadlines
• Familiarity with common denial rationales and documentation requirements
• Disciplined handling of protected health information (PHI)