Broadway Ventures
Medical Review 2 - Medicare
Full-Time
$62k - $65k/yr
Junior, Mid
Remote in USA
Remote
No H1B Sponsorship
About the job
Requirements
- An active, unrestricted Registered Nurse license is required; a compact license is preferred.
- A minimum of 2–3 years of clinical nursing experience is required; rehabilitation, acute care, or case management experience is preferred.
- Prior experience in Medicare medical review, utilization review, or claims review is strongly preferred.
- Working knowledge of Centers for Medicare & Medicaid Services coverage guidelines, Inpatient Rehabilitation Facility medical necessity criteria, and Medicare Administrative Contractor review processes is required.
- Strong analytical and clinical decision-making skills are required, including the ability to interpret medical records against regulatory criteria.
- Excellent written and verbal communication skills are required, including experience conveying review determinations directly to providers.
- Proficiency with Microsoft Office and claims or medical review software systems is required.
- The ability to consistently meet contractual review turnaround deadlines in a production-driven environment is required.
- Authorization to work in the United States without sponsorship is required.
Responsibilities
- Review all claims subject to medical review in accordance with applicable statutes, regulations, Centers for Medicare & Medicaid Services guidelines, and coverage requirements.
- Conduct pre-claim review for Inpatient Rehabilitation Facility services within designated review areas.
- Complete complex reviews of pre-claim review requests within two business days of receipt, including resubmissions.
- Complete pre-payment complex reviews of Additional Documentation Request responses within 30 calendar days of receipt.
- Complete post-payment complex reviews of Additional Documentation Request responses within 60 calendar days of receipt.
- Complete complex reviews of reopened Additional Documentation Request responses within 60 calendar days of receipt.
- Render affirmative or non-affirmative determinations on each pre-claim review request, assign a Unique Tracking Number per billing period, and treat incomplete documentation packages as non-affirmed.
- Conduct provider phone calls to communicate review determinations and provide education on non-affirmed decisions.
- Maintain accurate and timely documentation of all review activity in accordance with contract and Centers for Medicare & Medicaid Services requirements.
Desired Qualifications
- Rehabilitation, acute care, or case management background.
- Direct experience with Inpatient Rehabilitation Facility documentation and Centers for Medicare & Medicaid Services Review Choice Demonstration programs.
- Certification in case management, utilization review, or a related specialty, such as Certified Case Manager or Accredited Case Manager.