The Medical Review Nurse 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
• Participate in establishing edit parameters
• Participate in establishing new issue packets
• Participate in development of Medical Review Guidelines
• 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:

• Strong preference for experience performing utilization review for an insurance company, Tricare, MAC or organizations performing similar functions
• Experience with utilization management systems or clinical decision making tools such as Medical Coverage Guidelines (MCG) or InterQual.
• Experience with 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.
• Not currently sanctioned or excluded from the Medicare program by the OIG.
• Active unrestricted RN or LPN license in good standing, is required.

• 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
• Work independently and with team members effectively.

Additional Requirements:

Ability to obtain and maintain client required clearances as well as pass company regular background and/or drug screening.

Completion of Teleworker Agreement upon hire, and adherence to the Agreement (and related policies and procedures) including, but not limited to: able to navigate computer and phone systems as a user to work remote independently using on-line resources, must have high-speed internet connectivity, appropriate workspace able to be compliant with HIPAA, safety & ergonomics, confidentiality, and dedicated work focus without distractions during work hours.

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.

Job is performed in a standard busy office environment with moderate noise level (or may be home-office setting subject to Company approval and Teleworker Agreement), sits at a desk during scheduled shift, uses office phone or headset provided by the Company for calls, making outbound calls and answering inbound return calls using an office phone system; views a computer monitor, types on a keyboard and uses a mouse.

Reads and comprehends information in electronic (computer) or paper form (written/printed).

Sit/stand 8 or more hours per day; has the option to stand as needed while on calls; reach as needed to use office equipment.

Consistently viewing a computer screen and types frequently, but not constantly, using a keyboard to update accounts.

Consistently communicates on the phone as required primarily within the department and company and may include client contacts or other third-party depending on assignment with account holders, may dial manually when need or use dialer system; headset is also provided.

Occasionally lift/carry/push/pull up to 10lbs.

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.

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