Medical Review RN
Quality Health Strategies - Houston, TX

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Health Integrity, LLC, is a wholly owned subsidiary of the Quality Health Strategies Group. The Centers for Medicare and Medicaid awarded Health Integrity the Zone Program Integrity Contract for the southwestern portion of the United States. Under this contract, we are responsible for detecting and deterring fraud, waste and abuse in the Medicare Part A, Part B, Durable Medical Equipment and Home Health benefits. We are currently seeking experienced Medical Review RN's to perform medical record and claims reviews for our Houston, TX office. This position has the potential to work from home!

This mid-level professional position performs medical record and claims reviews for Medicare to ensure that proper regulatory guidelines have been followed. The Medical Review RN acts as a facilitator, working with the investigative team to assess for potential overpayment, fraud, waste, and abuse with regards to Medicare Parts A and B, Home Health, Hospice, and DME.

Performs complex prepayment and/or postpayment medical reviews on services billed to Medicare and/or Medicaid. Serves as a clinical resource for investigators, data analysts, and management. Collaborates with other team members when dealing with challenging medical reviews. Participates on proactive project teams as needed.Demonstrates ability to consistently achieve production standards. Serves as a mentor for new team members as needed. Meets with Law Enforcement representatives to discuss review specifics as needed. May serve as an investigative team member by participating in onsite provider and/or beneficiary interviews. Participates in internal and external focus groups, as required. Identifies opportunities to improve processes and procedures. Has the responsibility and authority to perform their job and provide customer satisfaction. Relies on experience and judgment to plan and accomplish goals. Performs a variety of tasks requiring independent thought and research.

Required Skills

Required Experience

A BSN; or RN with additional degree in a relevant healthcare discipline; or RN with a current and active specialty certification (ie: CPC, CCM, CPHQ, CFE, AHFI, HCQM) is required. Must possess at least five years clinical experience. At least five years clinical experience in conducting utilization reviews, ICD-9 coding, CPT coding, and knowledge of Medicare and/or Medicaid regulations preferred. Prior successful experience with CMS, State Medicaid, and OIG/FBI or similar agencies preferred.