Medical Review Nurse

🕒 5 days ago

🇺🇸 United States – Remote

⏰ Full Time

🟡 Mid-level

🟠 Senior

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Verse

WebsiteLinkedInAll Job Openings

11 - 50 employees

🏥 Healthcare

📦 Logistics

💼 Consulting

Healthcare • Logistics • Consulting

Verse is a company that provides in-home healthcare services for the 21st century, utilizing software that enables high-quality and reliable care at home. The company offers an easy-to-use software platform for clinics, allowing them to track all care referrals and orders efficiently. With coverage in all 50 states, Verse acts as an extension of clinics, saving nurses time and resources. They accept all insurances and focus on delivering a reliable patient experience. Their platform aims to streamline communication and logistics, eliminating the need for traditional methods such as fax and phone.

📋 Description

• Policy → Practice • Interpret and operationalize LCD L33831 + Policy Article for surgical dressings; publish practical rules (when covered, limits, documentation phrases). • Stand up “go/no‑go” criteria for collagen, alginate/fiber‑gelling, foam, film, hydrocolloid; codify A‑modifier (wound count) usage, KX/GA/GZ/EY, sizing, quantity/frequency math. • Pre‑Bill Controls • Build a 2‑gate QA (1: clinical completeness; 2: billing correctness) and pilot it on all surgical‑dressing claims. • Create/upgrade templates for various outreach. • Audit & Appeals • Lead UPIC/MAC ADR responses (pre‑ and post‑pay). • Coach internal billing team; establish a reusable appeals library with policy citations and exemplars. • Enablement & Analytics • Train customer-facing team members (30‑min modules) and billers on the specific documentation that satisfies the LCD. • Define and track metrics: initial denial %, appeal win %, ADR turnaround, % packets with signed POD, top‑defect Pareto.

🎯 Requirements

• 3-5+ years medical‑review experience at a UPIC or MAC (e.g., Safeguard Services, Qlarant, CoventBridge; Noridian, CGS, NGS, WPS, Novitas, Palmetto). • Hands‑on adjudication of surgical dressings (A6021 collagen; A6196–A6199 alginate/fiber‑gelling; A6209–A6215 foam; A6212–A6214 bordered foam; A6216–A6221 gauze; A6257–A6259 film). • Expert with proof‑of‑delivery standards, SWO requirements, frequency/sizing rules, and common denial rationales (e.g., two‑cover stacking, over‑frequency without rationale, DOS/POD mismatch). Most of our interview process is focused on your practical experience with the coverage guidelines. • Crisp, policy‑anchored writing; calm under deadline; disciplined with PHI.

🏖️ Benefits

• Health insurance • Retirement plans • Paid time off • Flexible work arrangements • Professional development