Medical Review Nurse

We are seeking a Registered Nurse for fully remote role to perform complex medical record and claim reviews (Standard or Program Integrity) to make coverage determinations based on applicable Medicare coverage policies and payment rules, coding guidelines, National and Local Coverage Determinations, utilization/practice guidelines, clinical review judgment and when appropriate, monitor for potential indicators of fraud, waste, and abuse. Provides professional assessment, planning, coordination, implementation, and reporting of complex data ***Job Description:*** ***Job Description Title : Medical Review Nurse*** ***Duration: Long Term Contract*** ***Location : Remote*** MUST HAVE Medicare experience, not Medicare advantage, but have experience in all of Medicare. 3 years is the required minimum. Their role includes comparing medical records to the bill to make sure it’s coded correctly and determine if the services provided were of medical necessity. If they disagree with how something was billed, they determine why it wasn’t necessary and go forth from there. They are checking the checkers basically. The items they are reviewing is for care that has already been delivered. Looking for individuals who have reviewed many different types of claims. In this role, they will come across anything / everything that can be billed to Medicare, from inpatient hospital services, durable medical equipment, physical therapy, drug/alcohol abuse and behavioral health. Because of all of the different types of claims they come in contact with, need to be able to go out on the web and search for the guidelines for each of the services that are being given. Need to be moderately strong in ICD\-10 codes, but more importantly CPT and HCPCS. Pay: From $90,000\.00 per year Work Location: Remote