The Medical Review Nurse - CMS / RAC (Government Audits) primarily performs medical claims audit reviews for government clients. As a MR Nurse, you will join a team of experienced medical auditors and coders performing retrospective and prepayment audits on claims for Government Payers. You will work remotely in a fast paced and dynamic environment and be part of a multi-location team.

Please note: RAC certification is preferred for this role. The selected candidate may need to work toward RAC certification if they do not currently have it.

Key Responsibilities

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

Knowledge, Skills and Abilities Needed

• Experience with utilization management systems or clinical decision-making tools such as Medical Coverage Guidelines (MCG) or InterQual.
• Experience with and deep knowledge of ICD-9, ICD-10, CPT-4 or HCPCS coding.
• Knowledge of insurance programs program, particularly the coverage and payment rules.
• Ability to maintain high quality work while meeting strict deadlines.
• Excellent written and verbal communication skills.
• Ability to manage multiple tasks including desk audits and claims review.
• 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
• Effectively work independently and as a team, in a remote setting.

Required and Preferred Qualifications

• Active unrestricted RN license in good standing, is required.
• Must not be currently sanctioned or excluded from the Medicare program by the OIG.
• Minimum of five (5) years diversified nursing experience providing direct care in an inpatient or outpatient setting.
• One (1) or more years' experience performing medical records review.
• 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.
• Strong preference for experience performing utilization review for an insurance company, Tricare, MAC, or organizations performing similar functions.
• RAC certification preferred.