Sr. Nurse Reviewer (Medicare)

Description

At Commence, we’re the start of a new age of data-centric transformation, elevating health outcomes and powering better, more efficient process to program and patient health. We combine quality data-driven solutions that fuel answers, technology that advances performance, and clinical expertise that builds trust to create a more efficient path to quality care.

With human-centered, healthcare-relevant, and value-based solutions, we create new possibilities with data. We provide proof beyond the concept and performance beyond the scope with a focus on efficiencies that transform the lives of those we serve. With a culture driven by purpose, straightforward communication and clinical domain expertise, Commence cuts straight to better care.?

Requirements

The Senior Nurse Reviewer performs complex medical record reviews of Medicare Part A/B and DMEPOS claims that require clinical judgment in order to assess the potential for overpayment or fraud.   Using established criteria/ and clinical guidelines, the Senior Nurse Reviewer is responsible for making medical determinations as to the validity of health claims and levels of payment in meeting national and local policies as well as accepted medical standards of care. 

The Senior Nurse reviewer may also have responsibilities for managing and overseeing the medical review work of a team, to include various quality review activities along with the development of training materials.  The Senior Nurse Reviewer is responsible for driving continuous improvement by identifying and implementing process enhancements, while supporting team accountability and maintaining high-quality performance standards. 

Required Qualifications 

• Bachelor's degree in nursing or a related healthcare field  
• Active, unrestricted RN license; compact multistate RN license acceptable 
• 5+ years of clinical experience, including 3+ years of Medicare-related utilization review, medical review, or claims review experience 
• Demonstrated experience providing guidance, mentorship, or lead-level direction to other clinical reviewers (RN/LPN) and/or coding staff 
• Extensive knowledge of Medicare coverage, coding, and payment rules, including NCD/LCD application 
• Strong analytical, written, and verbal communication skills; ability to handle confidential/sensitive information with discretion 

Preferred Qualifications 

• Prior experience as a senior/lead reviewer or “Medical Reviewer III”-equivalent on a MAC, RAC, QIO, or SMRC-type contract 
• Experience participating in inter-rater reliability or peer-review quality assurance programs 
• CPC (or similar) coding certification 
• Experience supporting case file preparation for Administrative Law Judge (ALJ) hearing participation 

Key Responsibilities 

• Conduct the highest-complexity and escalated clinical medical reviews, including reassigned cases where the original reviewer is no longer available, consistent with SOW continuity requirements for Discussion & Education sessions 
• Serve as a mentor and technical resource for Nurse Reviewers and Certified Coders on complex, mixed clinical/coding claims 
• Lead or contribute to inter-rater reliability and peer-review QA activities supporting the SOW's required 95%+ monthly accuracy standard  
• Contribute to development and maintenance of medical review training materials and the Quality Control assessment plan  
• Monitor team-level accuracy and quality trends; recommend corrective actions and process improvements to the Medical Review Manager 
• Support vulnerability identification and trend/root-cause analysis for Program Integrity reviews 
• Complete required annual CMS trainings and maintain HIPAA/PHI compliance 

Work Environment/Physical Demands

The work environment and physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

This is a remote position. While performing the duties of this job, the employee regularly works in a climate-controlled environment. Candidates must be able to sit, read, work on a computer, and watch a computer screen for extended periods of time. Occasionally required to stand, walk, use hands and fingers, kneel or crouch.

Commence is an equal employment opportunity for employer. All personnel processes are merit-based and applied without discrimination on the basis of race, color, religion, sex, sexual orientation, gender identity, marital status, age, disability, national or ethnic origin, military and veteran status or any other characteristic protected by applicable law.

Commence.AI is committed to providing equal employment opportunities to all applicants, including individuals with disabilities. If you require reasonable accommodation to participate in the application process due to a disability, please contact Human Resources at (757) 306-4920 or [email protected]. Please note that unless you are requesting an accommodation, all applications must be submitted through our online application system.