The Medicare Part A/Part B Medical Review Nurse reviews a medical claim and assesses patient's records documenting the treatment that was administered by a physician or facility (hospital, nursing home care, hospice or home health service) in order to determine appropriate payment.
Previous experience as a Medicare Part A and/or Part B Medical Review Nurse working for a Medicare Administrative Contractor (MAC)
Previous experience as a Registered Nurse in a clinical setting
Must have an active RN license in resident state and hold a compact license
Must have working knowledge of HCPCS, CPT and ICD-9 and/or ICD-10 codes, as well as CMS guidelines, MCS and FISS.
Requires excellent verbal and written communication skills
Excellent analytical and problem-solving skills with the ability to make independent decisions
Must have strong technical skills (Microsoft Windows, keyboarding skills, strong systems aptitude, etc.)
Ability to remain focused and productive each day though tasks may be repetitive Responsibilities:
Review all billing to determine if a treatment is covered by the patient's coverage plan and if that treatment was medically necessary
Navigate claims systems and imaging software simultaneously to review both pre-payment and post-payment claims
Review and make determinations on cases on appeal or denials due to medical necessity of services and/or reasonableness and necessity of services
Consult resources such as the Milliman Care Guidelines (MCG) and document all decisions using protocol sets or clinical guidelines Preferred Qualifications:
Previous successful work at home experience
About the Company
BroadPath provides specialized business, compliance, and technology services to healthcare payers and providers in commercial and government sectors.
We focus solely on healthcare, so our team understands our clients' issues in a way few others can. And since we work with the country's top healthcare organizations, we have unique insight into the industry's best practices and of the dynamics and regulations affecting operations and outcomes.
Employment Type: Permanent
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