UPIC Medical Review Nurse

Company: Noridian Healthcare Solutions ( Learn More )

General Information
US-LA-New Orleans
Not Specified
Not Specified
Not Specified
Job Description


The UPIC Medical Review Nurse conducts medical record and claims review for Medicare, Medicaid, and/or other claims data in order to ensure proper guidelines, coding, billing, and application of medical policy have been followed during the course of fraud investigations or other program integrity initiatives. Documents clear justification to support findings and providers. Identifies potential fraud, waste, or abuse through various means and determines the appropriateness of proceedings with an investigation or audit. As a member of the investigative team, incumbent may act as a facilitator as well as a case manager regarding assessment for potential overpayment, fraud, waste, and abuse with regards to Medicare, Medicaid, and/or other claims. Provides expert witness testimony as required.


Investigation and Coding Audits: Reviews professional and institutional claims and corresponding records to verify that coding and billing are appropriate based on current guidelines and medical policy. Determines the most effective and efficient methods of investigation based on each case Analyzes the data collected from internal and external resources that supports the investigation. Documents all steps of investigations and preserves evidence per established procedures. Applies knowledge of Medicare/Medicaid/Commercial insurance rules and regulations pertaining to appropriate billing and coding of accounts.

Review of Claims for Medical Necessity: Performs independent medical necessity reviews of claims for a large variety of services. Addresses claims processing issues and coding. May assist with reimbursement inquiries related to medical review determinations. Follows how-to-process guidelines while utilizing research skills to apply the appropriate medical policies/medical guidelines/criteria/reference materials to complete the review. Researches trends, inconsistencies, and inaccuracies with specific claims and claims history. Communicates, documents, and provides rationalizations when claims need additional review from Medical Directors and all other additional stakeholders.

Maintaining Medical Review (MR) Activities: Identifies potential fraud, waste, or abuse through the use of software, tips, data analysis, and other available means. Determines the appropriateness of proceeding with an investigation or audit. Utilizes claims tracking tools to identify and prioritize MR work to ensure timeliness within appropriate guidelines. Enters MR activities into claim processing system and departmental tracking programs/database timely. Identifies and corrects differences in determinations through quality assurance/quality initiative programs. Monitors changes in federal, state, or local MR process changes and checks for accuracy in contractor review determinations for needed changes of MR processes.

Job Requirements


Nursing Knowledge Professional: Maintains a vast knowledge base of professional nursing theory, techniques, practices and procedures and a considerable knowledge of medical terminology, disease process, and body systems. Understands current clinical diagnostic procedures and treatments and skills in applying these to individual cases. Remains current on general knowledge of state and federal rules and regulations governing financial reimbursement and the impact they have when applied across the nursing continuum.

Communication: Effectively collaborates and communicates with external or internal contacts to clearly represent the business needs. Communicates, facilitates, and presents to individuals and/or groups at all levels within the organization. Possesses a clear, straightforward and reasonably concise style in writing documents. Pays attention to detail, including spelling and grammar. Effectively transfers thoughts, information and ideas.

Problem Solving/Critical Thinking - Health Care: Assesses and interprets medical and clinical information from a patient chart. Evaluates a plan of nursing intervention to meet the needs of individual patients. Makes accurate decisions based upon the review of medical records and makes recommendations for improvements in nursing services. Has a structured approach to solving problems, demonstrates planning and analytical skills to deliver on results.

Analysis and Decision Making: Uses effective approaches for choosing a course of action or developing appropriate solutions and/or researching conclusions. Takes action consistent with available facts, constraints, and anticipated consequences.

Continuous Learning & Development: Follows and believes in an ongoing approach to personal learning and development. Seeks out educational opportunities, and alternative mechanisms which lend themselves to gaining new job related information, methodologies, and skills. Makes independent decisions based upon a mixture of analysis, experience, judgement, and advice from others.

Interpersonal Collaborations: Builds strong relationships with others inside and outside the organization. Responds and relates well to people in all positions. Is a team player and is cooperative. Aligns problem solving efforts around a shared goal or purpose.


Constant Innovation: Seizes opportunities to advance progressive change.

Service Excellence: Provides value through quality service.

Responsible Stewardship: Manages all resources entrusted to them with efficiency and care.

Effective Collaboration: Works together towards a common purpose.

Integrity: Does the right thing


Education Details: Bachelor's degree in Nursing is required (BSN)

Experience Details: Minimum of 5 years clinical experience required. Healthcare experience that demonstrates expertise in conducting utilization reviews, ICD-9 coding, CPT coding, and knowledge of Medicare/Medicaid regulations preferred. Prior successful experience with CMS, State Medicaid, and OIG/FBI or similar agencies preferred. Multi-specialty coding experience preferred.


Title: RN license

State or Agency (If Applicable): State Board of Nursing

Additional Details: Active RN licensure will need to be verified prior to hire date or transfer into position.


Job Posting Policy 6.05

New employees with Noridian Healthcare Solutions will be eligible to apply for positions within their assigned department after successfully completing a 90-day review. For positions outside your department, you must attain a minimum of six months of service before you can apply.


Equal Opportunity Employer of Minorities, Females, Protected Veterans and Individual with Disabilities, as well as Sexual Orientation or Gender Identity.

For questions, please email [Click Here to Email Your Resumé].

This job posting will be closed 2/03/2017 at 8:00AM CST. No further applications will be considered.