RN Medical Reviewer

Company: Nordian Healthcare Solutions

General Information
2 Year Degree
At least 3 year(s)
Up to 25%
Job Description Primary Objective of Position

The purpose of this job is to reduce medical necessity claim errors through complex medical review, requiring the analysis of available patient medical information, applying Medicare guidelines and then educate and train providers on the accurate submission of covered medically necessary services.



Essential Functions

1)      Review and analyze medical records. Make medical review decisions based upon all available resources including Medicare policies, guidelines and medical knowledge

a)      Research and gather all additional information necessary to make an accurate determinations by utilizing all available resource materials. Resources may include the following:

•         Knowledge of nursing practice and personal clinical experiences

•         Medicare guidelines policies and procedures

•         Internal control standards

•         Local Coverage Determinations

•         Medicare National Coverage Determinations

•         CMS Internet only manuals

•         Medicare Benefit Policy

•         Program Integrity Manual (PIM)

•         CMS Change Requests and Memorandums

•         Internal process manuals

•         HCPCS (Health Care Financing Administration Common

•         Procedure Coding System) publications which include CPT

•         International Classification of Diseases (ICD-10)

•         AMA (American Medical Association) Evaluation and

•         Management Documentation Guidelines

•         MR/CMS/CERT Reports

•         Medicare Coverage Database

•         All available Medical References

•         Contractor Medical Directors

•         All available Consultants

•         Medicare A and B News articles

•         Basic billing manual

•         Correspondence from Regional Office or Central Office


b)      Complete the medical review of the claim Determine whether services submitted are covered or non-covered by Medicare

•         Identify inaccurate coding of procedures, diagnoses or modifiers and assign applicable codes as needed

•         Identify any areas of potential aberrant practices by providers through medical review and refer for education, compliance, probes, WIC or fraud

•         Provide personal provider education for accurate submission of covered and non-covered services by phone or written correspondence through use of bulletins, workshops, telephone education, and web site updates or individual provider letters

c)       Ensure workload is processed in a timely and accurate manner in accordance with CMS standards

d)      Document workload for management on a daily basis



2)      Educate the provider/supplier community

a)      Use Progressive Corrective Action (PCA) to identify provider education requirements as appropriate then educate accordingly utilizing 1 on 1 provider phone calls and/or educational letters including all pertinent educational materials

b)      Provide professional customer service to assist providers in resolving issues

c)       Participate/facilitate conferences, provider education workshops and Carrier Advisory Committee (CAC)

d)      Create educational bulletin articles and assist with policies

e)      Use claims for appropriate education through correct denial messages and comments

f)       Evaluate the effectiveness of edits and audits in an ongoing basis and quarterly to assist Management in determining audit effectiveness

g)      Follow-up to ascertain that education was effective. Data may need to be requested from the Western Integrity Center (WIC)




3)      Keep abreast of changes in the medical community

a)      Maintain and ensure that educational materials and files are up to date

b)      Review CMS Correspondence

c)       Attend bulletin review meetings

d)      Attend team meetings

e)      Participate in CAC and Internal Policy meetings

f)       Communicate and disperse new medical information

g)      Attend internal and external medical inservices

h)      Maintain and keep nurse licensure current



4)      Function as an internal medical resource person

a)      Complete medical review decisions for the Hearings department

b)      Answer questions for other internal customers:

•         Call centers

•         Appeals

•         Education

•         Compliance

•         Adjudication 

•         Recoupment

•         Management

•         Audit

•         All other internal customers

c)       Assist in development, participation and presentation of internal inservice education



5)      Initiate and revise local coverage determination LCDs) and bulletin articles as issues are identified

a)      Reference appropriate LMRP and bulletin articles when processing claims

b)      When issues are found in claim review that need updating in a policy, bulletin or a new bulletin article, bring these issues to the Internal Policy meetings for discussion

c)       Attend and be aware of the CMS Correspondence

d)      Write any bulletin articles as needed



6)      Take initiative to develop and improve processed quality improvements (QI) and quality assurance (QA)

a)      Complete internal nurse review of claims for QI (Part A) and QA (Part A and B) on a weekly and quarterly basis

b)      Update and clarify Part A and Part B processes, as appropriate

c)       Identify processing problems and apply problem-solving techniques

d)      Identify and correct differences in review outcomes through QA and QI processes and meetings



7)      Utilize good communication skills. Effective communication is an integral part of all preceding essential functions

a)      Maintain strict confidentiality in all communications

b)      Actively practice working skills to internal and external customers

•   Oral

•   Written

•   Telephone

c)       Document in the appropriate reporting forms

d)      Make written reports and forms clear to all readers



8)      Contribute positively to a team based work environment through behaviors and values

a)      Maintain corporate values and divisional goals

b)      Maintain personal and team integrity

c)       Participate in team meetings, chairmanship of meetings and take and review minutes

d)      Initiate develop, and implement process improvements

e)      Provide and seek feedback on issues

f)       Take initiative to streamline and improve processes

g)      Contribute to and maintain spreadsheets, databases and logs as established



9)      Consistent regular attendance is required

Job RequirementsKnowledge

•         Medical policies and procedures

•         Nursing theory and practices

•         Basic PC

•         Will learn: -Medicare rules and regulations/guidelines; -Medicare insurance claims processing

•         CPT 4 and ICD 10 Medical diagnosis coding



•         Research, analyze, and interpret detailed medical records and policies, benefits, and established guidelines

•         Ability to make decisions/problem solving skills

•         Proven oral and written communication skills

•         Organize and prioritize workload in order to meet standards and deadlines

•         Self-starter goal oriented individual

•         Work independently and in a team environment

•         Operate basic office equipment (e.g. keyboard, fax, copy, telephone, etc.)

•         Ability to travel



•         An active Registered Nurse/RN license in the state the reviewer is working from and 2 years clinical/hospital/nursing home experience (exposure to Medicare claims processing a plus)



Other Information

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 Employment OpportunityEqual 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 00/00/0000 at 8:00AM CST. No further applications will be considered.