Medical Review SME (Full-time, Remote)

About Us

Integrity Management Services, Inc. (IntegrityM) is an award-winning, women-owned small business specializing in assisting government and commercial clients in compliance and program integrity efforts, including the prevention and detection of fraud, waste and abuse in government programs. Results are achieved through data analytics, technology solutions, audit, investigation, and medical review.

At IntegrityM, we offer a culture of opportunity, recognition, collaboration, compassion and supporting our community. We thrive off of these fundamental elements that make IntegrityM a great place to work. Our small, flexible workplace offers an exceptional quality of life and promotes corporate-driven sustainability. We deliver creative solutions that exceed goals and foster a dynamic, idea-driven environment that nurtures our employees’ professional development. Large company perks…Small company feel!

We are now seeking a Medical Review SME to join our team.

Requirements

• Minimum of three (3) years’ experience practicing nursing as a licensed Registered Nurse
• A minimum of three (3) years’ experience in a supervisory/managerial role in the health insurance industry
• Extensive knowledge of state and federal healthcare regulations, policies, coverage guidelines, and reimbursement rules in making clinical determinations
• Extensive experience performing medical review and/or utilization/QA reviews;
• Extensive knowledge of the Medicaid and/or CHIP program, particularly the coverage, conditions of payment, and state-specific policy requirements for health care coverage and payment
• Hold a Bachelor’s degree in Nursing.
• Current Registered Nurse Licensure.
• CPC Certification or the ability to obtain this certification or similar coding certification within 12 months of appointment.