Senior Nurse Reviewer, Medicare

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⚔️ Virginia – Remote

⚔️ Virginia – Remote

💵 $88k - $115k / year

⏰ Full Time

🟠 Senior

👻 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 of Medicare Part A/B and DMEPOS claims • Assess potential overpayment or fraud using established criteria and clinical guidelines • Make medical determinations regarding claim validity and payment levels under national and local policies and accepted standards of care • Manage and oversee medical review work of a team • Conduct quality review activities and develop training materials • Drive continuous improvement through process enhancements • Conduct highest-complexity and escalated clinical medical reviews, including reassigned cases • Mentor and provide technical guidance to Nurse Reviewers and Certified Coders on complex clinical/coding claims • Lead or contribute to inter-rater reliability and peer-review quality assurance activities • Support the required 95%+ monthly accuracy standard • Develop and maintain medical review training materials and the Quality Control assessment plan • Monitor team accuracy and quality trends and recommend corrective actions and process improvements to the Medical Review Manager • Support vulnerability identification and trend/root-cause analysis for Program Integrity reviews • Complete required annual CMS trainings and maintain HIPAA/PHI compliance

🎯 Requirements

• Bachelor's degree in nursing or a related healthcare field • Active, unrestricted RN license; compact multistate RN license acceptable • 5+ years of clinical experience • 3+ years of Medicare-related utilization review, medical review, or claims review experience • Experience providing guidance, mentorship, or lead-level direction to other clinical reviewers (RN/LPN) and/or coding staff • Extensive knowledge of Medicare coverage, coding, and payment rules, including NCD/LCD application • Strong analytical, written, and verbal communication skills • Ability to handle confidential/sensitive information with discretion • Prior experience as a senior/lead reviewer or “Medical Reviewer III”-equivalent on a MAC, RAC, QIO, or SMRC-type contract (preferred) • Experience participating in inter-rater reliability or peer-review quality assurance programs (preferred) • CPC or similar coding certification (preferred) • Experience supporting case file preparation for Administrative Law Judge (ALJ) hearing participation (preferred) • Ability to sit, read, work on a computer, and watch a computer screen for extended periods • Completion of required annual CMS trainings • HIPAA/PHI compliance

🏖️ Benefits

• Fully remote work arrangement • Reasonable accommodations for individuals with disabilities • Equal employment opportunity and nondiscrimination