Medical Review Nurse - Full-time / Part-time

The Medicare Part A/Part B Medical Review Nurse reviews a medical claim and assesses patient’s records documenting the treatment that was administered by a physician or facility (hospital, nursing home care, hospice or home health service) in order to determine appropriate payment.
Basic Qualifications: 

• Previous experience as a Medicare Part A and/or Part B Medical Review Nurse working for a Medicare Administrative Contractor (MAC)
• Previous experience as a Registered Nurse in a clinical setting
• Must have an active RN license in resident state and hold a compact license
• Must have working knowledge of HCPCS, CPT and ICD-9 and/or ICD-10 codes, as well as CMS guidelines, MCS and FISS.
• Requires excellent verbal and written communication skills
• Excellent analytical and problem-solving skills with the ability to make independent decisions
• Must have strong technical skills (Microsoft Windows, keyboarding skills, strong systems aptitude, etc.)
• Ability to remain focused and productive each day though tasks may be repetitive

• Review all billing to determine if a treatment is covered by the patient’s coverage plan and if that treatment was medically necessary
• Navigate claims systems and imaging software simultaneously to review both pre-payment and post-payment claims
• Review and make determinations on cases on appeal or denials due to medical necessity of services and/or reasonableness and necessity of services
• Consult resources such as the Milliman Care Guidelines (MCG) and document all decisions using protocol sets or clinical guidelines

• Previous successful work at home experience