Medical Review Nurse II - Clinical Validation

ABOUT PERFORMANT:

At Performant, we’re focused on helping our clients achieve their goals by providing technology-enabled services which identify improper payments and recoup or prevent losses due to errant billing practices. We are the premier independent healthcare payment integrity company in the US and a leader across several markets, including Medicare, Medicaid, and Commercial Healthcare. Through this important work we accomplish our mission: To offer innovative payment accuracy solutions that allow our clients to focus on what matter most – quality of care and healthier lives for all.

If you are seeking an employer who values People, Innovation, Integrity, Fun, and fostering an Ownership Culture – then Performant is the place for you!

ABOUT THE OPPORTUNITY:

Hiring Range:$69,300 - $78,000

The Medical Review Nurse II - Clinical Validation primarily 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 remotely in a fast paced and dynamic environment and be part of a multi-location team.

Key Responsibilities:

• Auditing claims for medically appropriate services provided in both inpatient and outpatient settings while applying appropriate medical review guidelines, policies and rules.

• Document all findings referencing the appropriate policies and rules.

• Generate 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.

Knowledge, Skills and Abilities Needed:

• Experience with utilization management systems or clinical decision-making tools such as Medical Coverage Guidelines (MCG) or InterQual.

• Experience with and deep knowledge of ICD-9, ICD-10, CPT-4 or HCPCS coding.

• Knowledge of insurance programs program, particularly the coverage and payment rules.

• Ability to maintain high quality work while meeting strict deadlines.

• Excellent written and verbal communication skills.

• Ability to manage multiple tasks including desk audits and claims review.

• Must be able to independently use standard office computer technology (e.g. email telephone, copier, etc.) and have experience using a case management system/tools to review and document findings.

• Must be able to manage multiple assignments effectively, create documentation outlining findings and/or documenting suggestions, organize and prioritize workload

• Effectively work independently and as a team, in a remote setting.

Required and Preferred Qualifications:

• Active unrestricted RN license in good standing, is required.

• Must not be currently sanctioned or excluded from the Medicare program by the OIG.

• Minimum of five (5) years diversified nursing experience providing direct care in an inpatient or outpatient setting.

• One (1) or more years' experience performing medical records review.

• One (1) 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.

• Strong preference for experience performing utilization review for an insurance company, Tricare, MAC, or organizations performing similar functions.

WHAT WE OFFER:

Performant offers a wide range of benefits to help support a healthy work/life balance. These benefits include medical, dental, vision, disability coverage options, life insurance coverage, 401(k) savings plans, paid family/parental leave, 11 paid holidays per year, as well as sick time and vacatio