Medical Review Nurse

The Medical Review Nurse (MRN) will support the Federal Team by reviewing medical claims to ensure services are reasonable, necessary, and compliant with national/local policies and coding practices. The role involves assessing Medicare Beneficiary records, evaluating medical coding, and making determinations based on established guidelines. The MRN may also participate in discussions with providers and stakeholders regarding case or project details.
\n Duties and Responsibilities:Reviews complex medical records, billing, and claims cases/projectsEvaluates coding practices to ensure accuracy and complianceApplies clinical guidelines and coverage criteria during case/project reviewsCommunicates with stakeholders as needed to support case review and resolutionDrafts inquiry letters, investigation findings, and case summariesInvestigates potential fraud leads and refers them to the appropriate resourcesResponsible for data entry, tracking, and reporting related to specific cases and projectsPerforms other duties related to the program as assigned QualificationsActive, current, and unrestricted Registered Nurse (RN) license3-5 years of experience in medical review, claims review, or coding reviewExperience with inpatient services and related carePreferred background in medical claims review and making medical determinations from record reviewsPrior Medicare Part A and B claims review experience, including prior authorization or appeals, using established criteria for medical determinationsStrong analytical and research skillsExcellent written and verbal communication abilitiesProficient in working with various research and processing systemsExperienced with Microsoft Word, Excel, and PowerPoint
\n$125 - $145 a year
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