Medical Review Nurse

Verse Medical • Remote, Remote

3d

About The Position

Verse Medical is building modern software infrastructure to connect providers, payors, and patients, ensuring people get high-quality care reliably and right where they live. This role is crucial in ensuring surgical dressing orders are compliant with CMS regulations and translating complex policies into practical rules and processes. The Medical Reviewer will play a key part in shaping the future of at-home care by managing compliance, auditing, appeals, and training.

Requirements

• 3-5+ years of medical-review experience at a UPIC or MAC (e.g., Safeguard Services, Qlarant, CoventBridge; Noridian, CGS, NGS, WPS, Novitas, Palmetto).
• Hands-on adjudication experience with surgical dressings (specific HCPCS codes listed).
• Expertise with proof-of-delivery standards, SWO requirements, frequency/sizing rules, and common denial rationales.
• Strong practical experience with coverage guidelines.
• Crisp, policy-anchored writing skills.
• Ability to remain calm under deadline pressure.
• Discipline in handling Protected Health Information (PHI).

Responsibilities

• Interpret and operationalize LCD L33831 + Policy Article for surgical dressings, publishing practical rules for coverage, limits, and documentation.
• Establish "go/no-go" criteria for various surgical dressing types and codify A-modifier usage, KX/GA/GZ/EY codes, sizing, and quantity/frequency calculations.
• Build and pilot a 2-gate QA process for clinical completeness and billing correctness on all surgical-dressing claims.
• Create and upgrade templates for various outreach communications.
• Lead UPIC/MAC ADR responses (pre- and post-pay).
• Coach the internal billing team and establish a reusable appeals library with policy citations and exemplars.
• Train customer-facing team members and billers on specific documentation requirements.
• Define and track key metrics such as initial denial percentage, appeal win percentage, ADR turnaround time, percentage of packets with signed POD, and top-defect Pareto.

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Education Level: No Education Listed