The Medical Review Nurse (MRN) will support the Federal Team by reviewing medical claims to ensure services are reasonable, necessary, and compliant with national/local policies and coding practices. The role involves assessing Medicare Beneficiary records, evaluating medical coding, and making determinations based on established guidelines. The MRN may also participate in discussions with providers and stakeholders regarding case or project details.

Duties and Responsibilities:

Reviews complex medical records, billing, and claims cases/projects
Evaluates coding practices to ensure accuracy and compliance
Applies clinical guidelines and coverage criteria during case/project reviews
Communicates with stakeholders as needed to support case review and resolution
Drafts inquiry letters, investigation findings, and case summaries
Investigates potential fraud leads and refers them to the appropriate resources
Responsible for data entry, tracking, and reporting related to specific cases and projects
Performs other duties related to the program as assigned

Qualifications

Active, current, and unrestricted Registered Nurse (RN) license
3-5 years of experience in medical review, claims review, or coding review
Experience with inpatient services and related care
Preferred background in medical claims review and making medical determinations from record reviews
Prior Medicare Part A and B claims review experience, including prior authorization or appeals, using established criteria for medical determinations
Strong analytical and research skills
Excellent written and verbal communication abilities
Proficient in working with various research and processing systems
Experienced with Microsoft Word, Excel, and PowerPoint

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Medical Review Nurse