[Hiring] Nurse Reviewer @Commence

Role Description

The Nurse Reviewer performs complex medical record reviews of Medicare Part A/B and DMEPOS claims that require clinical judgment in order to assess the potential for overpayment or fraud. Using established criteria and clinical guidelines, the Nurse Reviewer is responsible for making medical determinations as to the validity of health claims and levels of payment in meeting national and local policies as well as accepted medical standards of care.

Qualifications

• Graduation from an accredited school of nursing with current, unrestricted licensure as a Registered Nurse (RN); active compact multistate RN license acceptable.
• License recognized in the jurisdiction(s) relevant to the assigned work; for federal contract work, license must be issued by a body within the United States.
• 2–4 years of clinical experience, with demonstrated ability to apply clinical judgment to medical necessity, coverage, and appropriateness-of-care determinations under NCDs, LCDs, and CMS coverage policy.
• Detail-oriented, with strong working knowledge of medical terminology and clinical documentation standards.
• Associate's degree (or accredited nursing diploma) in a healthcare-related field with a professional clinical background.
• Experience in medical/claims review, including pre- and post-payment claims reviews and/or utilization review.

Requirements

• Perform complex medical record reviews requiring clinical judgment on Medicare Part A/B and DMEPOS claims.
• Determine coverage, medical necessity, and appropriateness of services against NCDs, LCDs, and CMS coverage/payment policy.
• Document clear, defensible rationale for payment or denial recommendations.
• Identify evidence of medical record alteration or documentation patterns suggestive of fraud, waste, or abuse.
• Participate in provider education sessions, explaining review rationale directly to providers/suppliers.
• Support claim(s) re-review when additional documentation is submitted.
• Maintain a 95%+ individual accuracy score and participate in inter-rater reliability/peer-review QA activities.
• Complete required annual trainings and maintain HIPAA/PHI compliance.

Company Description

At Commence, we’re the start of a new age of data-centric transformation, elevating health outcomes and powering better, more efficient processes to program and patient health. We combine quality data-driven solutions that fuel answers, technology that advances performance, and clinical expertise that builds trust to create a more efficient path to quality care.

With human-centered, healthcare-relevant, and value-based solutions, we create new possibilities with data. We provide proof beyond the concept and performance beyond the scope with a focus on efficiencies that transform the lives of those we serve. With a culture driven by purpose, straightforward communication, and clinical domain expertise, Commence cuts straight to better care.