Sr. Nurse Reviewer (Medicare)
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
- Bachelor's degree in nursing or a related healthcare field
- Active, unrestricted RN license; compact multistate RN license acceptable
- 5+ years of clinical experience, including 3+ years of Medicare-related utilization review, medical review, or claims review experience
- Demonstrated experience providing guidance, mentorship, or lead-level direction to other clinical reviewers (RN/LPN) and/or coding staff
- Extensive knowledge of Medicare coverage, coding, and payment rules, including NCD/LCD application
- Strong analytical, written, and verbal communication skills; ability to handle confidential/sensitive information with discretion
Nice To Haves
- Prior experience as a senior/lead reviewer or “Medical Reviewer III”-equivalent on a MAC, RAC, QIO, or SMRC-type contract
- Experience participating in inter-rater reliability or peer-review quality assurance programs
- CPC (or similar) coding certification
- Experience supporting case file preparation for Administrative Law Judge (ALJ) hearing participation
Responsibilities
- Performs complex medical record reviews of Medicare Part A/B and DMEPOS claims that require clinical judgment in order to assess the potential for overpayment or fraud.
- Makes medical determinations as to the validity of health claims and levels of payment in meeting national and local policies as well as accepted medical standards of care.
- Manages and oversees the medical review work of a team, to include various quality review activities along with the development of training materials.
- Drives continuous improvement by identifying and implementing process enhancements, while supporting team accountability and maintaining high-quality performance standards.
- Conducts the highest-complexity and escalated clinical medical reviews, including reassigned cases where the original reviewer is no longer available, consistent with SOW continuity requirements for Discussion & Education sessions.
- Serves as a mentor and technical resource for Nurse Reviewers and Certified Coders on complex, mixed clinical/coding claims.
- Leads or contributes to inter-rater reliability and peer-review QA activities supporting the SOW's required 95%+ monthly accuracy standard.
- Contributes to development and maintenance of medical review training materials and the Quality Control assessment plan.
- Monitors team-level accuracy and quality trends; recommends corrective actions and process improvements to the Medical Review Manager.
- Supports vulnerability identification and trend/root-cause analysis for Program Integrity reviews.
- Completes required annual CMS trainings and maintains HIPAA/PHI compliance.
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What This Job Offers
Job Type
Full-time
Career Level
Senior
