Registered Nurse Medical Reviewer

Job Summary

Reviewing and analyzing Medicare claims, the part-time Medical Review Specialist V will determine payment eligibility based on coding, coverage, and utilization guidelines while working remotely.

Key responsibilities

• Conducts medical record claims reviews to ensure correct coding and medical necessity in accordance with CMS policies
• Analyzes claims for potential fraudulent billing practices and prepares summary reports for the Department of Justice
• Completes required claims reviews and reports within established production standards and timelines

Required qualifications

• Registered Nurse (RN) with current licensure in one or more states or D.C
• At least 10 years of clinical experience and a minimum of 7 years of claims knowledge
• Medical review experience is required, with previous fraud review/investigation experience preferred
• Proficiency in Microsoft Excel, Word, and various internet applications
• No pending adverse actions against any State or Federal licensing board