Nurse Reviewer – Medicare

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⚔️ Virginia – Remote

⚔️ Virginia – Remote

💵 $82k - $95k / year

⏰ Full Time

🟢 Junior

🟡 Mid-level

👻 Ghost score 0%

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LivantaLLC

WebsiteLinkedInAll Job Openings

201 - 500 employees

Founded 2004

🏥 Healthcare

💼 Consulting

⚕️ Healthcare Insurance

Healthcare • Consulting • Healthcare Insurance

Livanta LLC is a technology-enabled organization dedicated to advancing healthcare quality through innovation. It specializes in providing services to patients, caregivers, healthcare providers, and payers, focusing on improving health outcomes, navigating healthcare systems, and ensuring payment accuracy. Livanta is recognized as the largest Medicare Quality Improvement Organization and offers a range of services including quality oversight, auditing, advocacy, and data analytics to enhance patient care and safety while managing healthcare costs effectively.

📋 Description

• Perform complex medical record reviews requiring clinical judgment on Medicare Part A/B and DMEPOS claims • Determine coverage, medical necessity, and appropriateness of services against NCDs, LCDs, and CMS coverage/payment policy • Document clear, defensible rationale for payment or denial recommendations • Identify evidence of medical record alteration or documentation patterns suggestive of fraud, waste, or abuse • Participate in provider education sessions and explain review rationale directly to providers and suppliers • Support claim re-review when additional documentation is submitted • Maintain a 95%+ individual accuracy score and participate in inter-rater reliability and peer-review QA activities • Complete required annual trainings and maintain HIPAA/PHI compliance

🎯 Requirements

• Graduation from an accredited school of nursing • Current, unrestricted Registered Nurse (RN) licensure; active compact multistate RN license acceptable • License recognized in the jurisdiction(s) relevant to assigned work • For federal contract work, license issued by a body within the United States • 2–4 years of clinical experience • Ability to apply clinical judgment to medical necessity, coverage, and appropriateness-of-care determinations under NCDs, LCDs, and CMS coverage policy • Strong working knowledge of medical terminology and clinical documentation standards • Associate's degree or accredited nursing diploma in a healthcare-related field with a professional clinical background • Experience in medical/claims review, including pre- and post-payment claims reviews and/or utilization review • MAC or RAC appeals review experience (preferred) • CPC or similar coding certification (preferred) • Prior work as a Medicare medical review nurse for a MAC, RAC, QIO, or SMRC-type contractor (preferred) • Insurance industry experience (preferred) • Ability to sit, read, work on a computer, and watch a computer screen for extended periods • Ability to occasionally stand, walk, use hands and fingers, kneel, or crouch

🏖️ Benefits

• Fully remote position • Reasonable accommodations for individuals with disabilities • Equal employment opportunity and merit-based personnel processes