Medical Review II (Medicare)
Core
Licensed Registered Nurse performing complex medical reviews of Medicare claims for Inpatient Rehabilitation Facility (IRF) services, including pre-claim, pre-payment, and post-payment determinations.
Role type
Licensed Registered Nurse (Medical Review)
Builds
Medicare claim determinations for IRF services
Domain
Healthcare / Medicare / Inpatient Rehabilitation
Deliverable
production ML models | product features | dashboards & analysis | research | client delivery | infrastructure | physical/clinical work
Required skills
Clinical nursing judgment, Medicare coverage guidelines interpretation, IRF medical necessity criteria, regulatory compliance, provider communication, claims review software proficiency, deadline management
Preferred skills
Rehabilitation or acute care background, Utilization review experience, CMS Review Choice Demonstration (RCD) knowledge, Case management certification (CCM/ACM)
Technologies
Microsoft Office, claims/medical review software systems
Responsibilities
Conduct pre-claim review (PCR) determinations for IRF services; Evaluate Additional Documentation Request (ADR) responses; Render affirmative or non-affirmative determinations on claims; Communicate review determinations to providers via phone; Maintain accurate documentation of review activity; Meet strict contractual turnaround deadlines
Seniority
Mid-level, hands-on IC