Medical Review Nurse (Government Outpatient Clinical Focus)

The Medical Review Nurse (Government Outpatient Clinical) 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 in a fast paced and dynamic environment and be part of a multi-location team.

In this role, you will be responsible for:

• Suggest ideas that may improve audit work flows
• Other duties as required to meet business needs
• Working collaboratively with the audit team to identify and obtain approval for particular vulnerabilities and/or cases subject to potential abuse
• Supporting your findings during the appeals process if requested
• Documenting all findings referencing the appropriate policies and rules
• Keep abreast of medical practice, changes in technology, and regulatory issues that may affect the our clients
• Work with the team to minimize the number of appeals
• Generating letters articulating audit findings
• Assist with QA functions
• Auditing claims for medically appropriate services provided in both inpatient and outpatient settings
• Work in partnership with our clients, CMD colleagues, and other contractors on improving medical policies, provider education, and system edits
• Interface with and support the Medical Director
• Assist with training team members
• Applying appropriate medical review guidelines, policies and rules
• Cross train in all clinical departments/areas

• Ability to maintain high quality work while meeting strict deadlines.
• Experience with ICD-9, ICD-10, CPT-4 or HCPCS coding.
• Strong preference for experience performing utilization review for an insurance company, Tricare, MAC or organizations performing similar functions
• Excellent written and verbal communication skills.
• Not currently sanctioned or excluded from the Medicare program by the OIG.
• Knowledge of insurance programs program, particularly the coverage and payment rules.
• Active unrestricted RN, LPN or LVN license in good standing.
• Experience with utilization management systems or clinical decision making tools such as Medical Coverage Guidelines (MCG) or InterQual.

• Must be able to independently use standard office computer technology (e.g. email telephone, copier, etc.) and have experience using a case management system/tools to review and document findings.
• Must be able to manage multiple assignments effectively, create documentation outlining findings and/or documenting suggestions, organize and prioritize workload
• Ability to manage multiple tasks including desk audits and claims review.
• Work independently and with team members effectively.

• Ability to obtain and maintain client required clearances as well as pass company regular background and/or drug screening.

• Completion of Teleworker Agreement upon hire, and adherence to the Agreement (and related policies and procedures) including, but not limited to: able to navigate computer and phone systems as a user to work remote independently using on-line resources, must have high-speed internet connectivity, appropriate workspace able to be compliant with HIPAA, safety & ergonomics, confidentiality, and dedicated work focus without distractions during work hours.

• Job is performed in a standard busy office environment with moderate noise level (or may be home-office setting subject to Company approval and Teleworker Agreement), sits at a desk during scheduled shift, uses office phone or headset provided by the Company for 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 mouse.

• Reads and comprehends information in electronic (computer) or paper form (written/printed).

• Sit/stand 8 or more hours per day; has the option to stand as needed while on calls; reach as needed to use office equipment.

• Consistently viewing a computer screen and types frequently, but not constantly, using a keyboard to update accounts.

• Consistently communicates on the phone as required primarily within the department and company and may include client contacts or other third-party depending on assignment with account holders, may dial manually when need or use dialer system; headset is also provided.

• Occasionally lift/carry/push/pull up to 10lbs.