Nurse Reviewer (Medicare)

Commence • Remote, VA

3d • $82,000 - $95,000 • Remote

About The Position

At Commence, we’re the start of a new age of data-centric transformation, elevating health outcomes and powering better, more efficient process to program and patient health. We combine quality data-driven solutions that fuel answers, technology that advances performance, and clinical expertise that builds trust to create a more efficient path to quality care. With human-centered, healthcare-relevant, and value-based solutions, we create new possibilities with data. We provide proof beyond the concept and performance beyond the scope with a focus on efficiencies that transform the lives of those we serve. With a culture driven by purpose, straightforward communication and clinical domain expertise, Commence cuts straight to better care.

Requirements

• Graduation from an accredited school of nursing with current, unrestricted licensure as a Registered Nurse (RN); active compact multistate RN license acceptable
• License recognized in the jurisdiction(s) relevant to the assigned work; for federal contract work, license must be issued by a body within the United States
• 2–4 years of clinical experience, with demonstrated ability to apply clinical judgment to medical necessity, coverage, and appropriateness-of-care determinations under NCDs, LCDs, and CMS coverage policy
• Detail-oriented, with strong working knowledge of medical terminology and clinical documentation standards
• Associate's degree (or accredited nursing diploma) in a healthcare-related field with a professional clinical background
• Experience in medical/claims review, including pre- and post-payment claims reviews and/or utilization review

Nice To Haves

• MAC or RAC appeals review experience
• CPC (or similar) coding certification
• Prior work as a Medicare medical review nurse for a MAC, RAC, QIO, or SMRC-type contractor
• Insurance industry experience

Responsibilities

• Perform complex medical record reviews requiring clinical judgment on Medicare Part A/B and DMEPOS claims
• Determine coverage, medical necessity, and appropriateness of services against NCDs, LCDs, and CMS coverage/payment policy
• Document clear, defensible rationale for payment or denial recommendations
• Identify evidence of medical record alteration or documentation patterns suggestive of fraud, waste, or abuse
• Participate in provider education sessions, explaining review rationale directly to providers/suppliers
• Support claim(s) re-review when additional documentation is submitted
• Maintain a 95%+ individual accuracy score and participate in inter-rater reliability/peer-review QA activities
• Complete required annual trainings and maintain HIPAA/PHI compliance

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Education Level: Associate degree