Conduct remote medical review of Medicare claims for inpatient rehabilitation facility services, including pre-claim review determinations and review of additional documentation requests. Communicate determinations to providers and use clinical judgment to assess documentation against coverage criteria and policy requirements. The work is production-driven and requires careful adherence to turnaround expectations.
Key Responsibilities
- Conduct pre-claim review determinations for IRF Medicare claims.
- Review Additional Documentation Request responses and evaluate supporting clinical records.
- Communicate review outcomes directly to providers.
- Apply Medicare, managed care, and medical review criteria or protocols as needed.
- Use Microsoft Office and related spreadsheet or database tools to support review work.
- Work independently while prioritizing cases and meeting contractual turnaround requirements.
- Maintain confidentiality and handle sensitive information appropriately.
Required
- Associate degree in nursing or graduation from an accredited school of nursing.
- Active RN license in the hiring state or an active compact multistate RN license.
- At least 2 years of clinical nursing experience.
Preferred
- Bachelor’s degree in nursing.
- At least 3 years of RN clinical experience.
- Experience in home health, rehabilitation, or broad medical-surgical nursing.
- Working knowledge of Medicare, managed care, and medical review procedures.
- Familiarity with Microsoft Excel, Access, or similar database tools.
Benefits & Perks
- Remote work.
- Pay range of $62,000 to $65,000.
- 401(k) with company match.
- Health, vision, and dental coverage.
- PTO that increases with tenure.
- Company-provided life insurance, with voluntary life options.
- Short-term and long-term disability coverage.