Medical Review Nurse III

  • Full Time
  • Remote

Website CES, LLC

Integrity At Work

ob Description Summary: 

Primarily responsible for conducting clinical reviews of medical records during the course of fraud investigations or other program integrity initiatives such as requests for information or in support of proactive data analysis efforts. Identify and recommend high ROI proactive studies for identification of proactive targets for fraud investigation and generating leads related to trending fraud schemes. Applies Medicare guidelines in making clinical determinations as to the appropriateness of payment coverage.   



Review information contained in Standard Claims Processing System files (e.g., claims history, provider files) to determine provider billing patterns and to detect potentially fraudulent or abusive billing practices or vulnerabilities in Medicare payment policies 
Utilize extensive knowledge of medical terminology, ICD-9-CM and ICD-10-CM, HCPCS Level II and CPT coding along with analysis and processing of Medicare claims.  Utilize Medicare and Contractor guidelines for coverage determination 
Coordinate and compile written Investigative Summary Reports in conjunction with PI Investigators upon completion of the records review 
Uses leadership and communication skill to work with physicians and other health professionals as well as external regulatory agencies and law enforcement personnel 
Provide training to UPIC staff on medical terminology, reading medical records, and policy interpretation 
Provide expert witness testimony as required 
Complete assignments in a manner that meets or exceeds the quality assurance goal of 98% accuracy 
Maintain chain of custody on all documents and follows all confidentiality and security guidelines 
Perform other duties as assigned by the Medical Review Supervisor that contribute to UPIC goals and objectives and comply with the Program Integrity Manual and Statement of Work guidelines and CMS directives and regulations 

Required qualifications/skills: 

Graduate from an accredited school of nursing and has an active license as a Registered Nurse (RN).  
Knowledge of, and the ability to correctly identify, Medicare coverage guidelines 
Excellent oral and written communication skills 
Proficient with Microsoft Word, Excel and Internet applications 
Ability to efficiently organize and manage workload and assignments 
A minimum of 4 years of utilization/quality assurance review and ICD-9/10-CM/CPT-4 coding experience 
A minimum of 4 years of experience in coding and abstracting, working knowledge of Diagnosis Related Groups (DRGs), 
Knowledge of Prospective Payment Systems and Medicare coverage guidelines is required 
Advanced knowledge of medical terminology and experience in the analysis and processing of Medicare claims, utilization review/quality assurance procedures, ICD-9/10-CM and CPT-4 coding, Medicare coverage guidelines, and payment methodologies (i.e., Correct Coding Initiative, DRGs, Prospective Payment Systems, and Ambulatory Surgical Center), NCPDP and other types of prescription drug claims is required 
Ability to read Medicare claims, both paper and electronic, and a basic knowledge of the Medicare claims systems is required 

Preferred qualifications/skills: 


Supervisory Responsibilities: 


Office Equipment (if a WFH position): 

A locking cabinet and/or desk appropriate for storing documents and electronic media 
A cross-cut or micro-cut (preferred) shredder. 
Broadband internet connection  
Phone line (land line or cellular)  

Physical Requirements: 

May require prolonged periods of sitting at a desk, working on a computer and conducting phone interviews  


Must have and maintain a valid driver’s license for the associate’s state of residence  
Travel may be required as necessary, with prior approval. All necessary travel expenses are reimbursable via GSA standards 
Must have no adverse actions pending or taken against him/her by any State or Federal licensing board or program; and must have no conflict of interest (COI) as defined in § 1154(b)(1) of the Social Security Act. 
Work can be performed remotely (preferably within one of the following midwestern states: IL, IN, IA, KS, KY, MI, MN, MO, NE, OH and WI).