Medical Review Nurse Analyst

About the role

The Medical Review Nurse Analyst is responsible for conducting clinical reviews of medical records to ensure compliance with regulatory and payer guidelines. This role ensures that providers are billing and being paid appropriately for services provided based on Medicare guidelines.

Responsibilities

• Review submitted claims to ensure that billed services are medically necessary and correctly coded based on Medicare guidelines.
• Prepare written clinical summaries and determinations with clear rationale for approvals, denials, or modifications.
• Educate providers in accordance with the Targeted Probe and Educate (TPE) program.
• Maintain compliance with federal and state regulations, CMS guidelines, and company policies.
• Stay current on clinical guidelines, medical policy updates, and industry best practices.

Requirements

• Aceessory’s (ASN) or Bachelor’s Degree in Nursing (BSN).
• Active RN license, applicable to state of practice in good standing.
• One (1) or more years of clinical experience in a healthcare setting (hospital, homecare, skilled nursing, etc.).
• Excellent written and verbal communication skills, with the ability to communicate complex medical information clearly and concisely.
• Strong attention to detail and organizational skills to manage multiple cases simultaneously.
• Basic knowledge and understanding of medical/clinical review processes.
• Solid computer skills with experience working in multiple on-line systems including MS Outlook, Teams, OneNote, Word, and Excel.

Qualifications

• Experience working for a Medicare Administrative Contractor (MAC) preferred.
• Basic Medicare knowledge and/or experience preferred.

Skills

• Ability to perform detailed reviews of medical records and documentation to determine the medical necessity of services.
• Strong attention to detail and organizational skills.
• Basic knowledge and understanding of medical/clinical review processes.
• Solid computer skills with experience working in multiple on-line systems.

Benefits

• Performance bonus and/or merit increase opportunities.
• 401(k) with a 100% match for the first 3% of your salary and a 50% match for the next 2% of your salary (100% vested immediately).
• Competitive paid time off.
• Health insurance, dental insurance, and telehealth services start DAY 1.
• Professional and Leadership Development Programs.

Pay

Salary Range: $68,000 - $72,000

Schedule

Remote Work Option Available