Medical Review Nurse

Epathusa; Clive (IA); Remote; USD 80,000 - 110,000; Full time

Job summary

ePATHUSA, Inc. is seeking a Registered Nurse for a fully remote, Medicare-focused medical record review role. You will evaluate Part A and B claims, ensure coding accuracy, and determine compliance with national and local coverage determinations.

The position supports AI-driven review processes and requires independent, detail-oriented work with high accuracy. Responsibilities include validating AI outputs, translating policy documents into structured rules, and collaborating with program

Qualifications

• Knowledge of ICD-9-CM, ICD-10, CPT-4 and HCPCS coding.
• Experience with Medicare Parts A and B policy and associated claims.
• Ability to read, analyze and interpret physician documentation.
• Strong research skills in Medicare, Medicaid and local healthcare regulations.

Responsibilities

• Review Medicare Part A and Part B payment policies for services and equipment.
• Assess AI-assisted policy translation accuracy for compliance determinations.
• Monitor for fraud, waste and abuse indicators in claims data.
• Maintain productivity and accuracy standards (98% IRR).
• Support program and technical teams in meeting deliverables.

Skills

ICD coding

CPT/HCPCS

Medicare policies

Medical record review

Documentation analysis

Research skills

Education

Bachelor's Degree in Nursing

BSN preferred

Tools

EMR software

InterQual/Milliman guidelines

Job description

Seeking Registered Nurse for fully remote role to perform complex medical record and claim reviews for various services and equipment (Medicare Part A and Part B) to make coverage determinations based on applicable Medicare coverage policies and payment rules, coding guidelines, National and Local Coverage Determinations, utilization/practice guidelines, clinical review judgment and when appropriate, monitor for potential indicators of fraud, waste, and abuse. Provides professional assessment, planning, coordination, implementation, and reporting of complex data to support the AI Medical Review Contract (AI MRR).Essential FunctionsReview of Medicare Fee-for-Service payment policies for various services and equipment covered in Medicare Part A and Part BReview of medical documentation for Medicare Fee-for-Service claims for various services and equipment covered in Medicare Part A and Part BEvaluation of the accuracy of an AI-assisted process to translate policy documents into structured rules for determining compliance with Medicare policyEvaluation of the accuracy of the determinations of an AI-assisted tool in recommending determinations of compliance with Medicare policyEvaluating the ease of integrating an AI-assisted tool into claim review processesSupport the Program Manager and technical teams in meeting deliverable schedulesWhen performing Program Integrity (PI) reviews, assess investigative allegations and medical review findings, and/or other claims data to determine patterns and detect potential indicators of fraud, waste and abuse (FWA)Consistently meet or exceed productivity and accuracy standards of 98% minimum IRR established by the customer and/or the Company.Required QualificationsA Registered Nurse, with a current unobstructed license to practice nursing in the United States. Graduate of a Board approved Registered Nursing program.A minimum of three (3) or more years’ experience in medical record review with Medicare Part A and Part B.Minimum of 2 (two) years’ experience in the medical review processes of MACs, SMRC, CERT, QICs and/or BFCC-QIOs.A minimum of five (5) years clinical experience in an acute care hospital, skilled nursing facility, and/or an office/clinic-based medical practicRequired Skills & AbilitiesWorking experience with electronic medical records or electronic transmission of medical records.Knowledge of ICD-9-CM, ICD-10, CPT-4 and HCPCS coding.Expertise in Medicare Part A policy, including inpatient hospital and other facility claims.Expertise in Medicare Part B policy, including outpatient and other physician services and durable medical equipment.Ability to work independently and maintain an elevated level of concentration.Capable of consistency, speed, and accuracy of task.Ability to read, analyze, and interpret physician documentation.Proficiency in research, interpretation, and application of, Medicare, Medicaid, and local healthcare regulations and policies.Self-motivated, well-organized, and detail oriented.Preferred QualificationsA Bachelor’s Degree in Nursing (BSN) or other related field.Certification in coding.Experience performing medical review for fraud, waste, and abuse (FWA) investigations.One year or more of utilizing InterQual and/or Milliman guidelines against inpatient services experience.Requirements for Federal Contract StaffingEligibility for federal background checks, including residence in the United States for at least 3 years out of the past 5 years