Nurse Remote Medical Review Specialist

About this role

Complex Medicare claims/prior authorization requests require the review of medical record documentation to determine the reasonableness and necessity of the billed service in accordance with Medicare rules and regulations. The reviews are performed by specially trained clinical staff using various methods to track the assignment, progress, and resolution of claims/cases. For complex claim reviews, the Companies are required to use Registered Nurses (“RNs”). Clinical decisions will be based on CMS policies/procedures defined in the CMS Internet-Only Manual (IOM), Company policies/procedures, Title XVIII of the Social Security Act (Section 1862), generally accepted standards of medical practice, clinical knowledge, contract guidelines, applicable Code of Federal Regulation guidelines, or other relevant statutory authority as applicable. Our staff will perform this work for Medical Reviews, Appeals, and/or Prior Authorization requests.
Qualified Staff and Work Location Requirements

• A valid RN license in any state and two years of clinical experience

• Bi-lingual preferred by not a must

• Associates Degree

• Preferred background in Home Health or Skilled nursing preferred

• Must have access to high-speed internet, be provided hardware for processing reviews.

• be available to perform work within the Company-specified core hours of 9:00 AM – 3:00 PM EST based on system availability.

• Pay rate between $30-$34 per hour plus benefits

Originally posted on Himalayas