Medical Review Nurse

ePathUSA • Clive, IA

3d • $76,875 - $97,375 • Remote

About The Position

The Medical Review Nurse performs complex medical record and claim reviews for Medicare Part A and Part B services and equipment. The role makes coverage determinations using applicable Medicare coverage policies and payment rules, coding guidelines, National and Local Coverage Determinations, utilization and practice guidelines, and clinical review judgment. When appropriate, the nurse monitors for potential indicators of fraud, waste, and abuse. The position provides professional assessment, planning, coordination, implementation, and reporting of complex data in support of the AI Medical Review Contract (AI MRR).

This is a fully remote, full-time role based in the listed location of Clive, Iowa. The position is classified as experienced, has a day shift, and involves negligible travel. The salary range is $76,875 to $97,375.

The nurse reviews Medicare policies and claim documentation, evaluates the accuracy and usability of AI-assisted tools and processes, and supports the Program Manager and technical teams in meeting deliverable schedules. The role requires meeting or exceeding productivity and accuracy standards, including a minimum 98% IRR established by the customer and/or the company.

Requirements

• Current, unobstructed Registered Nurse license to practice in the United States.
• Graduate of a Board-approved Registered Nursing program.
• At least three years of experience in medical record review with Medicare Part A and Part B.
• At least two years of experience with medical review processes for MACs, SMRC, CERT, QICs, and/or BFCC-QIOs.
• At least five years of clinical experience in an acute care hospital, skilled nursing facility, and/or office- or clinic-based medical practice.
• Working experience with electronic medical records or electronic transmission of medical records.
• Knowledge of ICD-9-CM, ICD-10, CPT-4, and HCPCS coding.
• Expertise in Medicare Part A policy, including inpatient hospital and other facility claims.
• Expertise in Medicare Part B policy, including outpatient and other physician services and durable medical equipment.
• Ability to work independently and maintain a high level of concentration.
• Ability to perform tasks consistently, quickly, and accurately.
• Ability to read, analyze, and interpret physician documentation.
• Proficiency in researching, interpreting, and applying Medicare, Medicaid, and local healthcare regulations and policies.
• Self-motivated, well-organized, and detail-oriented.
• Eligible for federal background checks, including having resided in the United States for at least three of the past five years.

Nice To Haves

• Bachelor’s Degree in Nursing (BSN) or another related field.
• Certification in coding.
• Experience performing medical review for fraud, waste, and abuse investigations.
• At least one year of experience using InterQual and/or Milliman guidelines to review inpatient services.

Responsibilities

• Review Medicare Fee-for-Service payment policies for services and equipment covered under Medicare Part A and Part B.
• Review medical documentation for Medicare Fee-for-Service claims involving services and equipment covered under Medicare Part A and Part B.
• Evaluate the accuracy of an AI-assisted process that translates policy documents into structured rules for determining compliance with Medicare policy.
• Evaluate the accuracy of determinations recommended by an AI-assisted tool for compliance with Medicare policy.
• Evaluate how easily an AI-assisted tool can be integrated into claim review processes.
• Support the Program Manager and technical teams in meeting deliverable schedules.
• For Program Integrity reviews, assess investigative allegations, medical review findings, and/or other claims data to identify patterns and potential indicators of fraud, waste, and abuse.
• Consistently meet or exceed productivity and accuracy standards, including a minimum 98% IRR established by the customer and/or the company.

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level