The Medical Review Nurse performs medical claims audit reviews. As a MR Nurse, you will join a team of experienced medical auditors and coders performing retrospective and prepayment audits on claims for Government, and Commercial Payers. You will work in a fast paced and dynamic environment and be part of a multi-location team.
In this role, you will be responsible for:
Auditing claims for medically appropriate services provided in both inpatient and outpatient settings
Applying appropriate medical review guidelines, policies and rules
Documenting all findings referencing the appropriate policies and rules
Generating letters articulating audit findings
Supporting your findings during the appeals process if requested
Working collaboratively with the audit team to identify and obtain approval for particular vulnerabilities and/or cases subject to potential abuse
Work in partnership with our clients, CMD colleagues, and other contractors on improving medical policies, provider education, and system edits
Keep abreast of medical practice, changes in technology, and regulatory issues that may affect the our clients
Work with the team to minimize the number of appeals
Suggest ideas that may improve audit work flows
Assist with QA functions
Participate in establishing edit parameters
Participate in establishing new issue packets
Participate in development of Medical Review Guidelines
Assist with training team members
Interface with and support the Medical Director
Cross train in all clinical departments/areas
Other duties as required to meet business needs
Required Skills and Knowledge:
Strong preference for experience performing utilization review for an insurance company, Tricare, MAC or organizations performing similar functions
Experience with utilization management systems or clinical decision making tools such as Medical Coverage Guidelines (MCG) or InterQual.
Experience with ICD-9, ICD-10, CPT-4 or HCPCS coding.
Knowledge of insurance programs program, particularly the coverage and payment rules.
Ability to maintain high quality work while meeting strict deadlines.
Excellent written and verbal communication skills.
Not currently sanctioned or excluded from the Medicare program by the OIG.
Active unrestricted RN license in good standing.
Ability to manage multiple tasks including desk audits and claims review.
Must be able to independently use standard office computer technology (e.g. email telephone, copier, etc.) and have experience using a case management system/tools to review and document findings.
Must be able to manage multiple assignments effectively, create documentation outlining findings and/or documenting suggestions, organize and prioritize workload
Work independently and with team members effectively.
Education and Experience:
- Sit/stand/ walk/8-10hr/day
- Lift/carry/push/pull under and over 10lbs occasionally
- Keying frequency, handling, reaching, fine manipulation
Minimum of three years diversified nursing experience providing direct care in an inpatient or outpatient setting.
One or more years experience performing medical records review.
One or more years experience in health care claims that demonstrates expertise in, ICD-9/ICD-10 coding, HCPS/CPT coding, DRG and medical billing experience for an Insurance Company or hospital required.
- Must submit to and pass background check.
- Must be able to pass a criminal background check; must not have any felony convictions or specific misdemeanors.
- Must submit to and pass drug screen.
Performant is a government contractor. Certain client assignments for this position requires submission to and successful outcome of additional background and/or clearances throughout employment with the Company.
Job Profile is subject to change at any time.
Performant Financial Corporation is an Equal Opportunity Employer. Performant Financial Corporation is committed to creating a diverse environment and is proud to be an equal opportunity employer. All qualified applicants will receive consideration for employment without regard to race, color, national origin, ancestry, age, religion, gender, gender identity, sexual orientation, pregnancy, age, physical or mental disability, genetic characteristics, medical condition, marital status, citizenship status, military service status, political belief status, or any other consideration made unlawful by law.