Medical Review II (Medicare)
Core
Licensed Registered Nurse performing complex medical review of Medicare claims for Inpatient Rehabilitation Facility (IRF) services, including pre-claim and post-payment determinations.
Role type
Licensed RN Medical Reviewer (Medicare)
Builds
Medicare claim determinations (affirmative/non-affirmative) for IRF providers
Domain
Healthcare / Medicare Compliance / Inpatient Rehabilitation
Deliverable
production ML models | product features | dashboards & analysis | research | client delivery | infrastructure | physical/clinical work
Required skills
Active RN licensure, complex medical review, CMS guidelines compliance, pre-claim review (PCR), Additional Documentation Request (ADR) evaluation, provider communication, documentation maintenance
Preferred skills
Bachelor's degree in Nursing, 3+ years clinical experience, managed care knowledge, home health/rehabilitation experience, Medicare regulations expertise, spreadsheet/database software proficiency
Technologies
Microsoft Office, Microsoft Excel, Access
Responsibilities
Review claims subject to medical review per statute and CMS guidelines; Conduct pre-claim review (PCR) for IRF services; Complete complex medical reviews of PCR, ADR, and reopened ADR requests within specified timelines; Render affirmative or non-affirmative determinations and assign Unique Tracking Numbers; Conduct provider phone calls to communicate determinations; Maintain accurate documentation of review activity
Seniority
Mid-level, hands-on IC