Job Summary
The Medical Review Nurse II is responsible for conducting retrospective and prepayment audits on medical claims from skilled nursing facilities, ensuring that the services provided are medically appropriate. This role involves documenting audit outcomes, creating comprehensive reports, and assisting in the appeals process while fostering collaboration with clients and internal stakeholders.
Responsibilities
- Conduct retrospective and prepayment audits of medical claims from skilled nursing facilities to assess medical appropriateness.
- Document and report findings from the audits clearly and effectively.
- Support the appeals process by providing necessary documentation and insights.
- Work in collaboration with both clients and internal teams to ensure compliance and accuracy.
Qualifications
- Must possess an active, unrestricted RN license.
- At least five years of diversified nursing experience is required.
- A minimum of one year of experience related to the MDS/RAI process and medical records review is necessary.
