Medical Review Nurse

  • Full Time
  • Remote
  • This position has been filled

Website CES, LLC

Integrity At Work

Job Description Summary: 

Nurse/Medical Reviewers utilize with case management of medical records, abstraction, and following policies for obtaining missing/incomplete medical record documentation, experience with medical records, knowledge of what constitutes required documentation in inpatient/ outpatient medical records, physician office records, laboratory/radiology, and other types of medical records will provide first level expertise in clinical documentation review. ICD-10-CM/CPT-4, and HCPCS Level II coding experience to conduct medical records and claims reviews. Upon hire, additional on-the-job training will be provided. 


Areas of Medical Review: 

Medicare PART A. These claim specialties include Hospice, End Stage Renal Disease (ESRD), Outpatient Rehabilitation Facilities (ORF), Outpatient Hospital, Rural Health Clinics and others. 
Medicare PART B. These claim specialties include Physician Offices, Ambulances, Physician Professional Services, Laboratory, and others. 
Medicare Durable Medical Equipment (DME) 




Utilize medical record knowledge and experience in order to determine completeness of medical records. 
Formulate written requests for additional medical record documentation. 
Apply knowledge of ICD-10-CM/CPT-4  and HCPCS Level II coding in order to determine services rendered. 
Sort and notate medical record layouts, formats, and abstraction for a variety of medical settings. 



Required qualifications/skills: 

Minimum Associates Degree or equivalent experience in relevant areas of expertise. 
At least 1 year of experience in clinical documentation review/abstraction. 
At least three (3) years clinical experience as a Registered Nurse 
Minimum two (2) years federal and local policy application in relation to Medicare insurance procedures for medical necessity for Outpatient Facilities and Services. 


Active RN license 



Preferred qualifications/skills: 

Previous experience with the review of medical claims and medical record requests. 
Previous utilization review experience. 


Ability to work as part of team and independently when necessary. 
Excellent oral and written communication skills to work effectively with team members, support personnel, and end users. 



Supervisory Responsibilities: 




Office Equipment Required: (This is a work from home position.) 

Locking cabinet and/or desk for storing documents and electronic media 
Cross-cut shredder 
Broadband internet connection 


Phone line (land line or cellular) 



Physical Requirements: 

May require prolonged periods of sitting at a desk and working on a computer. 




Must have no adverse actions pending or taken by any State or Federal licensing board or program 
Fingerprint background check may be required.