Registered Nurse - Medical Review Specialist - Remote in Bexar County, Texas - Medicare Claims Review and Quality Assurance
Join the Avosys Team as a Remote Registered Nurse - Medical Review Specialist
Avosys is a leading integrator of professional, technological, and management solutions services, proudly serving Federal, Commercial, Local, and State clients nationwide. Since our founding in 1998, we've prioritized the growth and well-being of our people, recognizing that they are the foundation of our success. We're now seeking a highly skilled and compassionate Registered Nurse - Medical Review Specialist to join our team remotely from Bexar County, Texas. As a Medical Review Specialist, you will play a crucial role in reviewing Medicare claims, ensuring compliance with CMS requirements, and providing high-quality patient care.
About Our Company Culture and Values
At Avosys, we value our employees' well-being and strive to create a work environment that supports work-life balance, professional growth, and community engagement. Our company culture is built on the principles of respect, integrity, and excellence. We believe in fostering a collaborative and inclusive work environment that encourages innovation, creativity, and teamwork. Our employees are our greatest asset, and we're committed to providing them with the resources and support they need to succeed.
Benefits and Perks
We offer a comprehensive benefits package, including:
Competitive salary and bonuses
Medical, dental, vision, life, short-term disability, and long-term disability insurance
401(k) retirement plan
Flexible work arrangements, including remote work options
No weekend, holiday, or on-call requirements
Guaranteed 8-hour shifts
Opportunities for professional growth and development
Job Summary
We're seeking a highly skilled Registered Nurse - Medical Review Specialist to review Medicare Part A and Part B claims, ensuring compliance with CMS requirements and regulations. As a Medical Review Specialist, you will be responsible for performing clinical reviews of Medicare claims, completing documentation of clinical decisions, and providing high-quality patient care. This is a unique opportunity to work remotely and make a meaningful impact on the lives of Medicare beneficiaries.
Key Responsibilities
As a Registered Nurse - Medical Review Specialist, your primary responsibilities will include:
Performing clinical reviews of Medicare Part A and Part B claims for Medical Review, Redeterminations/Appeals, and Prior Authorization requests
Completing a projected number of clinical review hours while meeting timeliness and accuracy standards
Reviewing medical record documentation within CMS timeliness parameters
Utilizing applicable Medicare policies to ensure compliance with all Medicare regulations and documentation requirements
Reviewing documentation for medical necessity per guidelines outlined in the Social Security Act 1862(a)(1)
Ensuring that all documentation includes a valid signature consistent with the signature requirements
Documenting rationale for processing decisions
Providing a claim sample of three claims to Companies via established protocols and timeliness parameters for quality review prior to finalization of documentation of reason for payment, reduction, or denial of service
Completing documentation of the reason for payment, reduction, or denial of service for all claims on an electronic decision template
Returning documented decisions electronically to Companies via established protocols and timeliness parameters
Completing review results letters in the Companies' letter writing system within specified timeframes
Documenting all case activity in Companies' provider tracking system on the day the activity occurs
Completing one-on-one provider education within 30 days of sending out review results letters
Responding to provider inquiries related to case and/or claims throughout the course of review
If additional clinical guidance is required, completing the Contractor Medical Director (“CMD”) assistance form, tracking response, and updating review accordingly
Conducting telephone development for missing or additional records for easily curable errors
Notating date of receipt of additional documentation received in the Companies' provider tracking system
Upon request by Companies, initiating or participating in provider teaching activities, creating written teaching material, providing one-on-one education or education to a group as a result of an MR review
If fraud activity is suspected, immediately completing initial referral packet for external entity referral and returning the packet to the Companies
Completing referrals to Companies' provider outreach and education (“POE”) area in provider tracking system for cases that have a moderate or major error rate
Participating in all monthly departmental training and meetings, and all Staff will participate as requested
Submitting all cases for review and approval for quality and closure of cases
Requirements and Qualifications
To be successful in this role, you will need:
Essential Qualifications:
Minimum of two (2) years' clinical experience as a Registered Nurse
Active and current Registered Nurse license
Excellent written and oral communication skills
Demonstrated experience with evaluating medical and health care delivery issues
Strong computer skills, including Microsoft Office proficiency
Preferred Qualifications:
Experience with Medicare claims review and quality assurance
Knowledge of CMS requirements and regulations
Experience with electronic health records and medical billing systems
Skills and Competencies
To excel in this role, you will need:
Strong analytical and critical thinking skills
Excellent communication and interpersonal skills
Ability to work independently and as part of a team
Strong organizational and time management skills
Ability to prioritize tasks and meet deadlines
Career Growth Opportunities and Learning Benefits
At Avosys, we're committed to providing our employees with opportunities for professional growth and development. As a Medical Review Specialist, you'll have access to:
Comprehensive training and onboarding program
Ongoing education and training opportunities
Career advancement opportunities within the company
Competitive salary and benefits package
Work Environment and Company Culture
We offer a remote work environment with flexible scheduling options. Our company culture is built on the principles of respect, integrity, and excellence. We believe in fostering a collaborative and inclusive work environment that encourages innovation, creativity, and teamwork.
Compensation and Benefits
We offer a comprehensive compensation and benefits package, including:
Competitive salary
Medical, dental, vision, life, short-term disability, and long-term disability insurance
401(k) retirement plan
Flexible work arrangements, including remote work options
How to Apply
If you're a motivated and compassionate Registered Nurse looking for a new challenge, we encourage you to apply for this exciting opportunity. Please submit your application, including your resume and cover letter, to [[email protected]](mailto:[email protected]) or call (210) 888-0775 for assistance.
Avosys is an equal opportunity employer and welcomes applications from diverse candidates. We're committed to providing a work environment that is inclusive and respectful of all employees.
Apply Now
Avosys is a leading integrator of professional, technological, and management solutions services, proudly serving Federal, Commercial, Local, and State clients nationwide. Since our founding in 1998, we've prioritized the growth and well-being of our people, recognizing that they are the foundation of our success. We're now seeking a highly skilled and compassionate Registered Nurse - Medical Review Specialist to join our team remotely from Bexar County, Texas. As a Medical Review Specialist, you will play a crucial role in reviewing Medicare claims, ensuring compliance with CMS requirements, and providing high-quality patient care.
About Our Company Culture and Values
At Avosys, we value our employees' well-being and strive to create a work environment that supports work-life balance, professional growth, and community engagement. Our company culture is built on the principles of respect, integrity, and excellence. We believe in fostering a collaborative and inclusive work environment that encourages innovation, creativity, and teamwork. Our employees are our greatest asset, and we're committed to providing them with the resources and support they need to succeed.
Benefits and Perks
We offer a comprehensive benefits package, including:
Competitive salary and bonuses
Medical, dental, vision, life, short-term disability, and long-term disability insurance
401(k) retirement plan
Flexible work arrangements, including remote work options
No weekend, holiday, or on-call requirements
Guaranteed 8-hour shifts
Opportunities for professional growth and development
Job Summary
We're seeking a highly skilled Registered Nurse - Medical Review Specialist to review Medicare Part A and Part B claims, ensuring compliance with CMS requirements and regulations. As a Medical Review Specialist, you will be responsible for performing clinical reviews of Medicare claims, completing documentation of clinical decisions, and providing high-quality patient care. This is a unique opportunity to work remotely and make a meaningful impact on the lives of Medicare beneficiaries.
Key Responsibilities
As a Registered Nurse - Medical Review Specialist, your primary responsibilities will include:
Performing clinical reviews of Medicare Part A and Part B claims for Medical Review, Redeterminations/Appeals, and Prior Authorization requests
Completing a projected number of clinical review hours while meeting timeliness and accuracy standards
Reviewing medical record documentation within CMS timeliness parameters
Utilizing applicable Medicare policies to ensure compliance with all Medicare regulations and documentation requirements
Reviewing documentation for medical necessity per guidelines outlined in the Social Security Act 1862(a)(1)
Ensuring that all documentation includes a valid signature consistent with the signature requirements
Documenting rationale for processing decisions
Providing a claim sample of three claims to Companies via established protocols and timeliness parameters for quality review prior to finalization of documentation of reason for payment, reduction, or denial of service
Completing documentation of the reason for payment, reduction, or denial of service for all claims on an electronic decision template
Returning documented decisions electronically to Companies via established protocols and timeliness parameters
Completing review results letters in the Companies' letter writing system within specified timeframes
Documenting all case activity in Companies' provider tracking system on the day the activity occurs
Completing one-on-one provider education within 30 days of sending out review results letters
Responding to provider inquiries related to case and/or claims throughout the course of review
If additional clinical guidance is required, completing the Contractor Medical Director (“CMD”) assistance form, tracking response, and updating review accordingly
Conducting telephone development for missing or additional records for easily curable errors
Notating date of receipt of additional documentation received in the Companies' provider tracking system
Upon request by Companies, initiating or participating in provider teaching activities, creating written teaching material, providing one-on-one education or education to a group as a result of an MR review
If fraud activity is suspected, immediately completing initial referral packet for external entity referral and returning the packet to the Companies
Completing referrals to Companies' provider outreach and education (“POE”) area in provider tracking system for cases that have a moderate or major error rate
Participating in all monthly departmental training and meetings, and all Staff will participate as requested
Submitting all cases for review and approval for quality and closure of cases
Requirements and Qualifications
To be successful in this role, you will need:
Essential Qualifications:
Minimum of two (2) years' clinical experience as a Registered Nurse
Active and current Registered Nurse license
Excellent written and oral communication skills
Demonstrated experience with evaluating medical and health care delivery issues
Strong computer skills, including Microsoft Office proficiency
Preferred Qualifications:
Experience with Medicare claims review and quality assurance
Knowledge of CMS requirements and regulations
Experience with electronic health records and medical billing systems
Skills and Competencies
To excel in this role, you will need:
Strong analytical and critical thinking skills
Excellent communication and interpersonal skills
Ability to work independently and as part of a team
Strong organizational and time management skills
Ability to prioritize tasks and meet deadlines
Career Growth Opportunities and Learning Benefits
At Avosys, we're committed to providing our employees with opportunities for professional growth and development. As a Medical Review Specialist, you'll have access to:
Comprehensive training and onboarding program
Ongoing education and training opportunities
Career advancement opportunities within the company
Competitive salary and benefits package
Work Environment and Company Culture
We offer a remote work environment with flexible scheduling options. Our company culture is built on the principles of respect, integrity, and excellence. We believe in fostering a collaborative and inclusive work environment that encourages innovation, creativity, and teamwork.
Compensation and Benefits
We offer a comprehensive compensation and benefits package, including:
Competitive salary
Medical, dental, vision, life, short-term disability, and long-term disability insurance
401(k) retirement plan
Flexible work arrangements, including remote work options
How to Apply
If you're a motivated and compassionate Registered Nurse looking for a new challenge, we encourage you to apply for this exciting opportunity. Please submit your application, including your resume and cover letter, to [[email protected]](mailto:[email protected]) or call (210) 888-0775 for assistance.
Avosys is an equal opportunity employer and welcomes applications from diverse candidates. We're committed to providing a work environment that is inclusive and respectful of all employees.
Apply Now