Medical Review Nurse (Home Health and Hospice)

Responsibilities :

The  Medical Review Nurse (Home Health and Hospice)  performs medical claims audit reviews. As a MR Nurse, you will join a team of experienced medical auditors and coders performing retrospective and prepayment audits on claims for Government, and Commercial Payers. You will work in a fast paced and dynamic environment and be part of a multi-location team.

In this role, you will be responsible for :

Auditing claims for medically appropriate services provided in both inpatient and outpatient settings

Applying appropriate medical review guidelines, policies and rules

Documenting all findings referencing the appropriate policies and rules

Generating letters articulating audit findings

Supporting your findings during the appeals process if requested

Working collaboratively with the audit team to identify and obtain approval for particular vulnerabilities and / or cases subject to potential abuse

Work in partnership with our clients, CMD colleagues, and other contractors on improving medical policies, provider education, and system edits

Keep abreast of medical practice, changes in technology, and regulatory issues that may affect the our clients

Work with the team to minimize the number of appeals

Suggest ideas that may improve audit work flows

Assist with QA functions

Assist with training team members

Interface with and support the Medical Director

Cross train in all clinical departments / areas

Other duties as required to meet business needs

• Note - All employees and contractors for Performant Financial may and / or will have access to Sensitive, Proprietary, Confidential and / or Public data. As such, all employees and contractors will have ownership and responsibility to report any violations to the Confidentiality and Integrity of Sensitive, Proprietary, Confidential and / or Public data at all times. Violations to Performant’s policy related to the Confidentiality or Integrity of data may be subject to disciplinary actions up to and including termination.

Required Skills and Knowledge :

Additional Requirements :

Physical Requirements :

Basic office equipment required to perform remote work is provided by the company.

Education and Experience :

Minimum of five years (Registered Nurse) or eight years (Licensed Practical Nurse / Licensed Vocational Nurse) of diversified nursing experience providing direct care in an inpatient or outpatient setting. RN license is preferred over LPN / LVN license for this role.

One or more years experience performing medical records review.

One or more years experience in health care claims that demonstrates expertise in, ICD-9 / ICD-10 coding, HCPS / CPT coding, DRG and medical billing experience for an Insurance Company or hospital required. (Preferred for clinical, mandatory for coding).

Other Requirements :

Performant is a Government contractor and subject to compliance with client contractual and regulatory requirements, including but not limited to, Drug Free Workplace, background requirements, and clearances (as applicable).

Employment VISA Sponsorship is not available for this position