What Is a Medicare Review Nurse and How to Become One
Table of Contents
What Does a Medicare Review Nurse Do?
A Medicare review nurse performs claim reviews to assess eligibility for Medicare coverage. You look at patient records and medical documents while evaluating claims. In some cases, your duties include investigating to see if a patient’s Medicare plan covers a medically-complex procedure or treatment. Your responsibilities can involve reviewing medical codes and records and communicating with doctors or other healthcare providers to gain additional information when needed. You can also flag claims for further fraud investigation. A nurse in this position may also ensure that healthcare providers have record-keeping and reporting practices that comply with Medicare rules.
How to Become a Medicare Review Nurse
The qualifications you need to become a Medicare review nurse include a nursing degree and state nursing license. You can start this career by either becoming a registered nurse (RN) or licensed practical nurse (LPN). You achieve this by first earning a postsecondary certificate (LPN) or degree (RN). You then need to pass an NCLEX exam to get your license. These positions require knowledge of medical coding and analytical skills to assess records and information. You also need to know laws and regulations related to Medicare. Some employers prefer applicants with experience in quality assurance, medical coding, or utilization review.
