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
