This role focuses on clinical medical record review for Medicare inpatient rehabilitation facility services, with an emphasis on pre-claim, pre-payment, post-payment, and reopened documentation reviews. The clinician evaluates records against CMS coverage and medical necessity criteria, makes affirmative or non-affirmative determinations, and communicates findings to providers. The work is production-driven and documentation-heavy, with timely turnaround expectations and routine use of review systems.
Key Responsibilities
- Review claims and medical records for compliance with statutes, regulations, CMS guidelines, and coverage requirements.
- Conduct pre-claim review for inpatient rehabilitation facility services.
- Complete complex pre-payment, post-payment, and reopened medical reviews within required turnaround times.
- Render affirmative or non-affirmative determinations and assign Unique Tracking Numbers as needed.
- Conduct provider phone calls to explain review decisions and provide education on non-affirmed cases.
- Maintain accurate, timely documentation of all review activity.
- Use claims and medical review software systems and Microsoft Office to support review workflow.
Required
- Active, unrestricted Registered Nurse license; compact license preferred.
- At least 2-3 years of clinical nursing experience.
- Working knowledge of CMS coverage guidelines, IRF medical necessity criteria, and Medicare Administrative Contractor review processes.
- Strong clinical judgment and ability to interpret medical records against regulatory criteria.
- Excellent written and verbal communication skills.
- Proficiency with Microsoft Office and claims/medical review software systems.
Preferred
- Experience with inpatient rehabilitation facility documentation.
- Experience with CMS Review Choice Demonstration programs.
- Background in rehabilitation, acute care, or case management.
- Certification in case management, utilization review, or a related specialty such as CCM or ACM.
Benefits & Perks
- 401(k) with company match.
- PTO that increases with tenure.
- Health, vision, and dental coverage.
- Company-provided life insurance, plus voluntary life insurance.
- Short-term and long-term disability coverage.