Medical Review Nurse III

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.

About the role

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 determine 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 and confidentiality of medical records and Protected Health Information (PHI) and Personally Identifiable Information (PII).
• Consistently meet attendance standards established by the Company and follow the telecommuting policy.
• Interact appropriately with peers, co-workers, other Contractors, and the customer, when necessary.
• Contribute to building a positive team spirit.
• Assist with development of training and/or resource materials as requested by the MRM or PM.
• Assist with precepting of new Medical Review Nurses (MRNs).
• Perform other duties and projects as assigned.

Requirements

• Registered Nurse, with a current unobstructed license to practice nursing in the United States.
• Graduate of a Board approved Registered Nursing program.
• A Bachelor’s Degree in Nursing (BSN) or other related field is preferred.
• Certification in coding highly preferred.
• A minimum of three (3) years clinical experience in an acute care hospital, skilled nursing facility, and/or an office/clinic-based medical practice.
• A minimum of three (3) or more years’ experience in medical/utilization medical record review particularly with Medicare and/or Medicaid.
• Proficiency in research, interpretation, and application of Medicare, Medicaid, and local healthcare regulations and policies.
• Must be proficient in Microsoft Office Suite such as Outlook, Excel, and Word.

Skills & Abilities

• Ability to work independently and maintain an elevated level of concentration.
• Capable of consistency, speed, and accuracy of task.
• Ability to read, analyze, and interpret physician documentation.
• One year or more of utilizing InterQual and/or Milliman guidelines against inpatient services experience is preferred.
• Ability to communicate clearly and professionally with all levels of the organization, both written and verbal.
• Ability to work well in a remote team environment, to collaborate with others, and interface with team members internal and external to the organization.
• Establishes and maintains effective professional relationships with internal and external stakeholders.
• Must be able to adapt to organizational change.
• Flexibility and ability to plan, prioritize, and execute multiple tasks in a fast-paced environment.
• Self-motivated, well-organized, and detail oriented.
• Ability to maintain a high level of confidentiality and integrity.

Pay

The annual salary range for this position is $80,000 to $95,000. Actual compensation will depend on a range of factors, including but not limited to the individual’s skills, experience, qualifications, certifications, location, other business and organizational needs, and applicable employment laws.

Benefits

RELI Group provides a variety of additional benefits to its employees. For additional details on the benefits that RELI Group offers click here.