Medical Review Nurse, RN (Registered Nurse)

Franklin, TN, US
Sep 13, 2017
Oct 14, 2017
Med / Surg
Contract Type
Job Description

Job Summary:

The Medical Review Nurse I is responsible for performing medical record review and evaluation of medical services being audited, analyzing submitted claims and available medical record documents to determine program compliance of Medicare benefit coverage, coding and documentation requirements for medical services under audit. The Medical Review Nurse I will also prepare written documents and reports of completed medical review determinations.

Primary Responsibilities:

  • Performs in-depth analysis and medical review of submitted medical records to determine program compliance of Medicare benefit coverage, coding and documentation requirements for medical services under audit

  • Prepares appropriate written documents/reports of individual review determinations in addition to overview reports that are understandable to a variety of audiences

  • Utilizes the appropriate regulations necessary to complete the medical record review

  • Provides appropriate determinations according to policies and regulations

  • Maintains internal control processes for all audit documentation in compliance with the Health Insurance Portability and Accounting Act (HIPAA)

  • Develops and maintains documentation for quality improvement processes

  • Provides expertise regarding administration, billing, and program regulations

  • Conducts research as necessary to complete the review

  • Conducts and participate in onsite visits as necessary

  • Participates in and contribute to the quality management system

Knowledge and Skill Requirements:

  • An active Registered Nursing License

  • Bachelors degree in nursing or related field required

  • Minimum of four years of experience, (clinical and/or medical record review) required

  • Prior functional working experience in medical records review arena preferred

  • Prior functional working knowledge of appropriate billing and coding guidelines preferred

  • Familiarity and understanding of the Medicare, Medicaid and/or Managed Care regulatory guidelines and associated requirements preferred

  • Ability to comprehend medical policy and criteria to clearly articulate health information

  • Minimum of one year of experience preparing written documentation and reports for a variety of audiences

  • Analytical, problem-solving and decision-making skills

  • Not sanctioned or excluded from the Government Programs by the OIG

  • Excellent written, oral and interpersonal communication skills

  • Proficiency in Microsoft Office, Word and Excel, Internet and e-mail

Working Conditions:

  • Typical office setting

  • Ability to express or exchange ideas to convey detailed or important spoken instructions to others

  • Ability to sit and work at a computer for an extended period using repetitive motion

  • Ability to prepare complex data and figures and/or complete extensive reading and research

  • Ability to occasionally travel

  • Ability to work extended hours as needed

  • Ability to work regular hours with predictable attendance on the job

    An Equal Opportunity/Affirmative Action Minority/Female/Veteran Disability, Employer

Company Description

StrategicHealthSolutions, LLC is making a difference for today, tomorrow and years to come to make Healthcare a sustainable resource. Our team of medical and technical experts are challenged every day to develop innovative ways to explain, improve and enforce healthcare policies through education and investigation. Knowing that we play a direct role in protecting and preserving affordable healthcare for the elderly, disabled and low-income population is what drives our strong work ethic and engaging work environment.

Similar jobs

More searches like this

Similar jobs