Registered Nurse Medical Reviewer

Job Summary

A company is looking for a Medical Review Specialist V.

Key Responsibilities

• Review and analyze Medicare claims and associated medical records to determine payment based on coverage and coding guidelines
• Conduct in-depth claims analysis for potential fraudulent billing practices and complete summary reports based on findings
• Ensure compliance with Medicare and DOJ guidelines while maintaining confidentiality and security of information

Required Qualifications

• Registered Nurse (RN) with current licensure in one or more states or D.C
• At least 10 years of clinical experience and a minimum of 7 years of claims knowledge
• Medical review experience is required; fraud review/investigation experience is preferred
• Ability to maintain confidentiality and adhere to ethical standards
• Proficient in Microsoft Excel, Word, and various internet applications