[Hiring] Medical Review Nurse - Readmissions @Performant Corp

Role Description

The Medical Review Nurse II - Readmissions primarily 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 remotely in a fast-paced and dynamic environment and be part of a multi-location team.

• Auditing claims for medically appropriate services provided in both inpatient and outpatient settings while applying appropriate medical review guidelines, policies, and rules.
• Document all findings referencing the appropriate policies and rules.
• Generate letters articulating audit findings.
• Support your findings during the appeals process if requested.
• Work 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 our clients.
• Work with the team to minimize the number of appeals; suggest ideas that may improve audit workflows; assist with QA functions and training team members.
• Participate in establishing edit parameters, new issue packets, and development of Medical Review Guidelines.
• Interface with and support the Medical Director and cross-train in all clinical departments/areas.
• Other duties as required to meet business needs.

Qualifications

• Knowledge of insurance programs, particularly the coverage and payment rules.
• Ability to maintain high quality work while meeting strict deadlines.
• Excellent written and verbal communication skills.
• Ability to manage multiple tasks including desk audits and claims review.
• Must be able to independently use standard office computer technology.
• Must be able to manage multiple assignments effectively, create documentation outlining findings and/or documenting suggestions, organize and prioritize workload.
• Effectively work independently and as a team, in a remote setting.

Requirements

• Active unrestricted RN license in good standing, is required.
• Must not be currently sanctioned or excluded from the Medicare program by the OIG.
• Minimum of five (5) years diversified nursing experience providing direct care in an inpatient setting.
• One (1) or more years' experience performing medical records review.
• One (1) 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.
• Other qualifications may be required and would be discussed during an interview.

Benefits

• Medical, dental, vision, HSA/FSA options.
• Life insurance coverage.
• 401(k) savings plans.
• Family/parental leave.
• Paid holidays.
• Paid time off annually.

Physical Requirements & Additional Notices

• If working in a hybrid or fully remote setting, access to reliable, secure high-speed Internet at your home office location is required.
• Regularly sits at a desk during scheduled shift, uses office phone or headset provided by the Company for phone calls, making outbound calls and answering inbound return calls using an office phone system; views a computer monitor, types on a keyboard and uses a computer mouse.
• Regularly reads and comprehends information in electronic (computer) or paper form (written/printed).
• Regularly sit/stand 8 or more hours per day.
• Occasionally lift/carry/push/pull up to 10lbs.