Medical Review Nurse Details

Medical Review Nurse

Williams Consulting LLC - Baltimore, MD

Employment Type : Full-Time

Williams Consulting LLC is seeking candidates for Medical Review Nurse positions to join our growing team. This is a 100% remote position in support of the Centers for Medicare and Medicaid Services.

HUBZone residents encouraged to apply

Williams Consulting LLC is an 8a, HUBZone and Woman-owned Small Business with Federal, State, Local and Commercial clients. We take great pride in our ability to provide exceptional customer service and we value our employees and recognize their contributions to the success of our clients and our company. We offer competitive salaries and support flexible work locations and scheduling, when possible. We offer competitive benefits including Medical, Vision, and Dental coverages through national plans. Life, AD&D, Short & Long Term Disability Insurance, PTO, and 401k.

Position Summary:

As a member of our Federal Team the Medical Review Nurse (MRN) will support to the Medical Claim/ Medical Review operations. This position applies clinical knowledge to assess and ensure services/items billed are reasonable and necessary, supported by national and local policies, are under accepted billing and coding practices, and meet standards of medical care. HUBZone candidates Preferred.

Responsibilities include but are not limited to making determinations based on established policies and procedures, reviewing Medicare Beneficiary medical records, evaluating medical coding practices and making determinations. The Medical Review Nurse role may also involve Case/Project discussions with impacted stakeholders including Providers and their representatives.

Duties and Responsibilities:

• Reviews Complex Medical Record and Billing/Claims Cases/Projects
• Evaluates Coding Practices
• Applies Clinical guidelines and other coverage/Medical criteria in reviewing cases/projects
• Interacts with various stakeholders as required to support case review
• Completes inquiry letters, investigation finding letters, and case summaries
• Investigates and refers all potential fraud leads to the appropriate identified resources
• Responsible for case specific and other required data entry, tracking and reporting
• Performs other related Program duties as assigned

Minimum Job Requirements:

• Active, current, valid, unrestricted Registered Nurse (RN) License
• Minimum of three to five (3-5) years of medical review experience/claims review experience
• Experience with in-patient and related services
• Medical experience preferred and experience in claims review and medical determinations based on medical record review
• Previous Medicare or Medicaid experience, including medical review, prior authorization or appeals, with experience utilizing established criteria to make medical review determination
• Proven Analytical and Research Skills
• Excellent written and verbal communication skills
• Experience working with multiple research/processing systems
• Experience working with MS Word, Excel, and PowerPoint

Successful Candidates Will Additionally Have the Following:

• Ability to successfully pass the required background checks
• Strong analytical skills
• Strong written and oral communication skills
• Proven track record in FWA related activities
• Computer skills with an emphasis on data entry, tracking and analysis and the ability to work well independently
• No Conflicts of Interest related due to other active employment (full or part-time)

Required License

• RN License
• HUBZone Residential Proof. Only if HUBZone Candidate
• Verify HUBZone address: https://maps.certify.sba.gov/hubzone/map#center=39.828200,-98.579500&zoom=5

Job-Type: Full-time

Salary: Negotiable

Location: 100% Remote

Work authorization: United States (Required)

This job requires you pass a background check:

• Yes

This job requires a drug screening:

• Yes

Williams Consulting LLC does not discriminate in employment on the basis of race, color, religion, sex, national origin, political affiliation, sexual orientation, marital status, disability, genetic information, age, membership in an employee organization, retaliation, parental status, military service, or other non-merit factor.