[Hiring] Medicare Medical Review RN @CoventBridge Group

Role Description

The Medicare Medical Review RN (Medical Reviewer III) will primarily be responsible for conducting clinical reviews of medical records during the course of fraud investigations or other program integrity initiatives such as requests for information or in support of proactive data analysis efforts. In addition, this position applies Medicare and Medicaid guidelines in making clinical determinations as to the appropriateness of payment coverage.

In assuming this position, you will be a critical contributor to meeting CoventBridge Group's objective: To provide services to our clients that exceed their expectations and contribute to improved healthcare delivery by identifying and eliminating fraud, waste and abuse.

This position will report directly to the Medical Review Supervisor and will work in our Grove City, OH office. If not local, remotely from a home office.

At this time, CoventBridge is not considering candidates who require visa sponsorship, currently or in the future, including but not limited to H-1B, H-2B, E-3, TN, O-1, F-1 (OPT/CPT, or J-1 Visa Statuses.)

Qualifications

• Graduate from an accredited school of nursing and have an active license as a Registered Nurse (RN) required
• Preference given to BSN or higher prepared nurses with recent medical review claims experience in Medicare or Medicaid reviews

Requirements

• 2 years minimum experience at a government contractor (ZPIC, UPIC, RAC, MAC, etc.)
• 2 years minimum working knowledge of ICS 10-CM/CPT coding experience
• 4 years minimum experience of working knowledge of Diagnosis Related Groups (DRG's), Prospective Payment Systems or Part B claims and Medicare coverage guidelines
• Knowledge of, and the ability to correctly identify, Medicare and Medicaid coverage guidelines
• Advance knowledge of medical terminology and experience in the analysis and processing of Medicare claims, utilization review/ quality assurance procedures, ICD 10-CM and CPT coding, Medicare coverage guidelines and payment methodologies (i.e., Correct Coding Initiative, DRG's, Prospective Payment Systems and Ambulatory Surgical center), NCPCP and other types of prescription drug claims
• Ability to read Medicare claims, both paper and electronic, and a basic knowledge of the Medicare claims systems is required
• Should possess excellent oral and written communication skills with an ability to write professional summary reports
• Knowledge of and ability to use Microsoft Word, Excel, and Internet applications
• Able to efficiently organize and manage workload and assignments
• Must have and maintain a valid driver' license for the associate's state of residence as onsite audits are part of the role as a nurse reviewer

Benefits

• Medical, Dental, Vision plans
• Life, LTD and STD paid by the employer
• 401(k) with company match up to 4%
• Paid Time Off and company paid holidays
• Tuition assistance after 1 year of service