Remote Medicare Nurse Reviewer: Claims & Compliance

Commence; Virginia (IL); On-site; USD 82,000 - 95,000; Full time

Job summary

Commence is seeking a Nurse Reviewer to perform expert medical record reviews of Medicare Part A/B and DMEPOS claims. You will apply clinical judgment to determine payment validity in line with national and local policies, documenting clear rationales for actions.

This remote role emphasizes HIPAA compliance and precise medical notation. The ideal candidate holds an RN license, an associate degree in nursing, 2–4 years of clinical experience, and familiarity with CMS coverage policies.

Qualifications

• RN license with current, unrestricted status
• Experience applying clinical guidelines to Medicare policies
• Detail-oriented with strong medical terminology knowledge
• Ability to document clear, defensible rationale for determinations

Responsibilities

• Perform complex medical record reviews for Medicare Part A/B and DMEPOS claims
• Assess coverage and medical necessity against NCDs, LCDs, CMS policies
• Document rationale for payment or denial decisions
• Identify evidence of record alteration or fraud indicators
• Educate providers on review rationale during sessions
• Support re-review when additional documentation is submitted and maintain high accuracy

Skills

Clinical judgment

Medical terminology

Detail-oriented

Communication

Education

RN license

Associate's degree in nursing

Job description

Commence is seeking a Nurse Reviewer to perform expert medical record reviews of Medicare Part A/B and DMEPOS claims. You will apply clinical judgment to determine payment validity in line with national and local policies, documenting clear rationales for actions.

This remote role emphasizes HIPAA compliance and precise medical notation. The ideal candidate holds an RN license, an associate degree in nursing, 2–4 years of clinical experience, and familiarity with CMS coverage policies.