Medical Review Nurse

Who is StrategicHealthSolutions, LLC (Strategic)? We are a recognized, respected, and trusted government contractor in the healthcare services industry, a CMMI Level 3 company and an ISO 9001 2008 certified provider of solutions for government health care programs.   We are headquartered in Omaha, NE (with other offices across the U.S.) and our dedicated and talented staff works closely with government entities to recoup misspent dollars and prevent future misuse through education, analytics, and investigation. We understand the importance of treating health care like any other resource, finite. We are taking a stand in the effort to protect our health care programs and our focus is to redefine health care as a sustainable resource and to protect the future of health care for generations to come!

Joining Strategic enables you to really make a difference, work with a great team of professionals and grow your capabilities. Our terrific total compensation package includes a generous salary, monetary retention incentives payable after 120 days and one year of employment, 15 days of paid time off, 10 paid annual holidays and a 401(k) with company match. And, of course, the other benefits – medical, dental, vision, life insurance, and short and long-term disability. Oh, and let’s not forget work schedule flexibility and promotional and professional development opportunities!

Job Summary:

The Medical Review Nurse I is responsible for performing medical record review and evaluation of medical services being audited, analyzing submitted claims and available medical record documents to determine program compliance of Medicare benefit coverage, coding and documentation requirements for medical services under audit. The Medical Review Nurse I will also prepare written documents and reports of completed medical review determinations.

Primary Responsibilities:

  • Performs in-depth analysis and medical review of submitted medical records to determine program compliance of Medicare benefit coverage, coding and documentation requirements for medical services under audit
  • Prepares appropriate written documents/reports of individual review determinations in addition to overview reports that are understandable to a variety of audiences
  • Utilizes the appropriate regulations necessary to complete the medical record review
  • Provides appropriate determinations according to policies and regulations
  • Maintains internal control processes for all audit documentation in compliance with the Health Insurance Portability and Accounting Act (HIPAA)
  • Develops and maintains documentation for quality improvement processes
  • Provides expertise regarding administration, billing, and program regulations
  • Conducts research as necessary to complete the review
  • Conducts and participate in onsite visits as necessary
  • Participates in and contribute to the quality management system

Knowledge and Skill Requirements:

  • An active Registered Nursing License
  • Bachelor’s degree in nursing or related field required
  • Minimum of four years of experience, (clinical and/or medical record review) required
  • Prior functional working experience in medical records review arena preferred
  • Prior functional working knowledge of appropriate billing and coding guidelines preferred
  • Familiarity and understanding of the Medicare, Medicaid and/or Managed Care regulatory guidelines and associated requirements preferred
  • Ability to comprehend medical policy and criteria to clearly articulate health information
  • Minimum of one year of experience preparing written documentation and reports for a variety of audiences
  • Analytical, problem-solving and decision-making skills
  • Not sanctioned or excluded from the Government Programs by the OIG
  • Excellent written, oral and interpersonal communication skills
  • Proficiency in Microsoft Office, Word and Excel, Internet and e-mail

Working Conditions:

  • Typical office setting
  • Ability to express or exchange ideas to convey detailed or important spoken instructions to others
  • Ability to sit and work at a computer for an extended period using repetitive motion
  • Ability to prepare complex data and figures and/or complete extensive reading and research
  • Ability to occasionally travel
  • Ability to work extended hours as needed
  • Ability to work regular hours with predictable attendance on the job

An Equal Opportunity/Affirmative Action Minority/Female/Veteran Disability, Employer

To build a diverse workforce, StrategicHealthSolutions, LLC encourages applications from individuals with disabilities, minorities and veterans.

In compliance with the American Disabilities Act Amendment Act (ADAAA), if you have a disability and would like to request an accommodation in order to apply for a position with Strategic, please call 402.452.3333 Ext. 246.  No other inquiries will be acknowledged.

StrategicHealthSolutions, LLC is an Equal Opportunity/Affirmative Action employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, or protected veteran status.