Medical Review Nurse (Snf Focus)

The Medical Review Nurse (SNF Focus) 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:

• Other duties as required to meet business needs
• Interface with and support the Medical Director
• Documenting all findings referencing the appropriate policies and rules
• 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
• Suggest ideas that may improve audit work flows
• Generating letters articulating audit findings
• Keep abreast of medical practice, changes in technology, and regulatory issues that may affect the our clients
• 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
• Cross train in all clinical departments/areas
• Assist with QA functions
• Work with the team to minimize the number of appeals
• Assist with training team members
• Applying appropriate medical review guidelines, policies and rules

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

• Must be able to manage multiple assignments effectively, create documentation outlining findings and/or documenting suggestions, organize and prioritize workload
• 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.
• Ability to manage multiple tasks including desk audits and claims review.
• Work independently and with team members effectively.

• 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. (Preferred for clinical, mandatory for coding).
• Minimum of five (5) years (Registered Nurse) or eight (8) years (Licensed Practical Nurse/Licensed Vocational Nurse) of diversified nursing experience providing direct care in an inpatient or outpatient setting. RN license is preferred over LPN/LVN license for this role.
• One (1) or more years experience performing medical records review.