Medical Review Nurse Analyst

About the role

The Medical Review Nurse Analyst conducts 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. The role reviews claims and educates providers on current billing and documentation requirements.

Responsibilities

• Perform detailed reviews of medical records and documentation to determine the medical necessity of services.
• Review submitted claims to ensure that billed services are medically necessary and correctly coded based on Medicare guidelines.
• Ensure Medicare providers are correctly reimbursed when documentation supports services rendered.
• 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.
• Monitor the progress of assigned providers and educate on current billing and documentation requirements.
• Ensure compliance with federal and state regulations, CMS guidelines, and company policies.
• Stay current on clinical guidelines, medical policy updates, and industry best practices.

Requirements

• Associate’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.

Preferred Qualifications

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

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.