Registered Nurse Medical Reviewer

Job Summary

A company is looking for a Medical Review Specialist IV.

Key Responsibilities

• Review and analyze Medicare claims and associated medical records for payment determinations
• Conduct in-depth claims analysis to detect potential fraudulent billing practices
• Complete summary reports and maintain compliance with departmental and regulatory guidelines

Required Qualifications

• Registered Nurse (RN) with current licensure in one or more states or D.C
• At least 4 years of clinical experience
• Minimum of 7 years of claims knowledge from billing, reviewing, or processing
• Medical review experience required; fraud review/investigation experience preferred
• No adverse actions pending or taken against licensure and no conflict of interest