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Registered Nurse

Company: RELI Group, Inc.
Location: Miramar
Posted on: September 13, 2020

Job Description:

Responsibilities:Perform complex medical reviews for program integrity focusing on situations of potential fraud, waste, and abuse in the Medicare and Medicaid ProgramsPerform accurate claim decision coverage determinations based on applicable Medicare and Medicaid coverage policies and payment rules, coding guidelines, National and Local Coverage Determinations, utilization/practice guidelines, and clinical review judgmentProvides professional assessment, planning, coordination, implementation, and reporting of complex data to support the Medical Review Accuracy Contract (MRAC)Perform accuracy review of complex Program Integrity (PI) Medicare and Medicaid medical record and claims review in accordance with all State and Federal mandated regulations/guidelinesPerform accuracy review of medical record and claims review, and assess investigative and medical review findings, and/or other claims data to determine patterns and detect potential fraud, waste and abuseAccurately analyze investigations, cases, and/or leads for accuracy reviewIdentify indicators of fraud, waste, and abuse and evaluate identification made during initial reviewRequirements:Registered Nurse--with a current unobstructed license to practice nursing in the United StatesGraduate of a Board approved Registered Nursing program--& not excluded or sanctioned from working with the Centers for Medicare and Medicaid ServicesA minimum of five (5) years clinical experience in an acute care hospital, skilled nursing facility, and/or an office/clinic-based medical practiceA minimum of three (3) or more years' experience in medical record review, particularly with Medicare and/or MedicaidMinimum of (1) one year of experience in CMS Program Integrity medical review investigation detection and analyzing/developing information in support of allegations of fraud, waste or abuseMust be proficient in Microsoft Office Suite such as Outlook, Excel, and Word.Ability to work well in a remote team environment, to collaborate with others, and interface with team members internal and external to the organizationStrongly Preferred but not required:A Bachelor's Degree in Nursing (BSN) or another related fieldCertification in codingProficiency in research, interpretation, and application of, Medicare, Medicaid, and local healthcare regulations and policiesEEO EmployerRELI Group is an Equal Employment Opportunity/Affirmative Action Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, age, sexual orientation, gender identity, national origin, disability, protected veteran status, or any other characteristic protected by law.--HUBZoneRELI Group is an established SBA certified HUBZone and 8(a) small business.-- We encourage all candidates who live in a HUBZone to apply.-- You can check to see if you address is located in a HUBZone by accessing the SBA HUBZone Map.--Powered by JazzHR

Keywords: RELI Group, Inc., Hollywood , Registered Nurse, Healthcare , Miramar, Florida

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