Medical Review Nurse III

Medical Review Nurse III

Responsibilities:

• Perform medical chart reviews of automated and complex medical records and claims in accordance with Federal regulations and guidelines.
• Conduct accuracy reviews as part of special studies requested by CMS.
• Compile reports of analysis and recommendations to submit to CMS.
• Assess investigative and medical review findings and analyze claims data to detect patterns of potential fraud, waste, and abuse.
• Perform accuracy reviews of medical records and claims, ensuring compliance with regulatory requirements.
• May handle more complex reviews and audits.

Qualifications & Requirements:

• Registered Nurse (RN) with a current, unobstructed license to practice in the United States.
• Graduate of a Board-approved Registered Nursing program.
• Bachelors Degree in Nursing (BSN) or a related field is preferred.
• Certification in medical coding is highly preferred.
• Minimum of three (3) years of clinical experience in an acute care hospital, skilled nursing facility, or office/clinic-based medical practice.
• Minimum of three (3) years of experience in medical/utilization review, particularly with Medicare and/or Medicaid.
• Proficiency in research, interpretation, and application of Medicare, Medicaid, and local healthcare regulations and policies.
• Strong proficiency in Microsoft Office Suite, including Outlook, Excel, and Word.