Medical Review Nurse III

About the role

At RELI Group, our work is grounded in purpose. We partner with government agencies to solve complex challenges, improve public health, strengthen national security, and make government services more effective and efficient. Our team of over 500 professionals brings deep expertise and a shared commitment to delivering meaningful outcomes. Behind every solution is a group of experts who care deeply about impact—whether we’re supporting data-driven decisions, modernizing systems or safeguarding critical programs. Perform automated and complex medical record and claim reviews to make coverage determinations based on applicable Medicare coverage policies and payment rules, coding guidelines, National and Local Coverage Determinations, utilization/practice guidelines, and clinical review judgment. Provides professional assessment, planning, coordination, implementation, and reporting of complex data to support the Recovery Auditor Validation Contract (RVC).

Responsibilities

• Perform accuracy review of automated and complex Medicare medical record and claims review in accordance with all State and Federal mandated regulations/guidelines.
• Perform accuracy reviews as a Special Study requested by CMS.
• Document findings for each claim in a clear and concise manner.
• Compile a report explaining the claim reviews, including identified patterns, inappropriate determinations, as well as recommendations.
• Reasonably determines appropriateness to consult a Subject Matter Expert (SME) for clarification.
• Perform medical record reviews in response to RAC disputes/disagrees with the RVC review decisions.
• Perform accuracy review of the New Issue Proposal for appropriate regulations, references, policies, and edit parameters.
• Compile a report of analysis and recommendations to submit to CMS.
• Perform New Issue Quality Assurance Review for accuracy of all criteria and references.
• Consistently meet or exceed productivity and accuracy standards of 95% minimum IRR established by the customer and/or the Company.
• Report problems to the Medical Review Manager (MRM) and Project Manager (PM) regarding unique record or process issues.
• Maintain security