Job description
The
Medical Review Nurse (SNF Focus) 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 our clients.
Work with the team to minimize the number of appeals; Suggest ideas that may improve audit workflows.
Assist with QA functions and training team members.
Participate in establishing edit parameters, new issue packets and development of Medical Review Guidelines.
Interface with and support the Medical Director and 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.
In this role, you will be responsible for:
Required Skills and Knowledge:
Additional Requirements:
Physical Requirements:
**NOTE: Must be able to meet requirements for and perform work assignments in accordance with Company policies and expectations on a home remote basis (and must meet Performant remote-worker requirements) until at which time staff may be notified and required to work from a Performant office location on an ad-hoc or periodic basis
.
Basic office equipment required to perform remote work is provided by the company.
Education and Experience:
- Minimum of three years diversified nursing experience providing direct care in an inpatient or outpatient setting.
- 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.
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).
- Must submit to and pass pre-hire background check, as well as additional checks throughout employment.
- Must be able to pass a criminal background check; must not have any felony convictions or specific misdemeanors, nor on state/federal debarment or exclusion lists.
- Must submit to and pass drug screen pre-employment (and throughout employment).
- Performant is a government contractor. Certain client assignments for this position requires submission to and successful outcome of additional background and/or clearances throughout employment with the Company.
- Applicants must have reliable, secure, high speed Internet access at their home office location.
Employment VISA Sponsorship is not available for this position
Job Profile is subject to change at any time.
EEO
Performant Financial Corporation is an Equal Opportunity Employer.
Performant Financial Corporation is committed to creating a diverse environment and is proud to be an equal opportunity employer. All qualified applicants will receive consideration for employment without regard to race, color, national origin, ancestry, age, religion, gender, gender identity, sexual orientation, pregnancy, age, physical or mental disability, genetic characteristics, medical condition, marital status, citizenship status, military service status, political belief status, or any other consideration made unlawful by law.
NO AGENCY SUBMISSIONS WITHOUT PERFORMANT AUTHORIZED AGENCY AGREEMENT AND APPROVED PERFORMANT JOB ORDER
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