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Medicare Medical Review Rn Jobs (NOW HIRING)

Lifehealth LLC

Medical Review RN

Washington, DC · On-site

$45/hr

Medical Review RN * Date: Start Date - TBD * Shift Time: 0800-1630 M-F * Location: Washington, DC Position Summary: LifeHealth Medical Review Nurse (MRN) is responsible for the initial chart review ...

Empower AI

Medical Reviewer III (Medicare/DRG)

$28.38/hr

Medical Review Specialist III (Medicare DRG) Empower AI gives federal agency leaders the tools to ... Review Lead Specialist Requirements: * Must be a Registered Nurse obtained by either a Bachelor ...

Saratoga Ascend

Medical Review Manager

Catonsville, MD · On-site

... for Medicare and Medicaid Services (CMS) in Catonsville, MD. The work hours are Monday to Friday ... S. and a currently licensed RN Minimum of five years of experience practicing as an RN in either an ...

Empower AI Inc.

Medical Reviewer III (Medicare/DRG)

$28.38/hr

... the Medical Review Lead Specialist Qualifications Requirements: * Must be a Registered Nurse ... Prior work as a Medicare Contractor Medical Review Nurse or Commercial Insurance * Optional ...

RELI Group Inc.

Medical Review Nurse III

Baltimore, MD · On-site +1

$80K - $95K/yr

Perform accuracy review of automated and complex Medicare medical record and claims review in ... Registered Nurse, with a current unobstructed license to practice nursing in the United States.

Peraton

Medical Review Nurse- Medicare

$66K - $106K/yr

Experience in the medical field as a Registered Nurse or other clinician, and/or experience in ... Experience in reviewing claims for technical requirements, performing medical review, and/or ...

Peraton

Medical Review Nurse- Medicare

$66K - $106K/yr

Experience in the medical field as a Registered Nurse or other clinician, and/or experience in ... Experience in reviewing claims for technical requirements, performing medical review, and/or ...

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Infographic showing various Medicare Medical Review Rn job openings in the United States as of September 2026, with employment types broken down into 1% As Needed, 78% Full Time, 15% Part Time, and 6% Contract. Highlights an 90% Physical, 1% Hybrid, and 9% Remote job distribution.

Medicaid Medical Review RN (Medical Reviewer III)

Remote

CoventBridge Group
11 - 50 employees
Learn more about CoventBridge Groupexternal

$78K - $85K/yr

Other

Medical, Dental, Vision, Life, Retirement, PTO

Re-posted 5 hours ago

CoventBridge Group rating

6.7

Company rating: 6.7 out of 10

Based on 13 frontline employees who took The Breakroom Quiz

309th of 500 rated business services

Job description

Overview
Medicaid Medical Review RN (Medical Reviewer III) - REMOTE
The Medicaid Medical Review RN (Medical Reviewer III) will primarily be responsible for conducting clinical reviews of medical records during the course of fraud investigations or other program integrity initiatives such as requests for information or in support of proactive data analysis efforts. In addition, this position applies Medicare and Medicaid guidelines in making clinical determinations as to the appropriateness of payment coverage.
In assuming this position, you will be a critical contributor to meeting CoventBridge Integrity System's objective: To provide services to our clients that exceed their expectations and contribute to improved healthcare delivery by identifying and eliminating fraud, waste and abuse.
This position will report directly to the Medical Review Supervisor and will work in our Grove City, OH office. If not local, remotely from a home office.
Responsibilities/ Requirements
Responsibilities:
  • Reviews information contained in Standard Claims Processing System files (e.g., claims history, provider files) to determine provider billing patterns and to detect potentially fraudulent or abusive billing practices or vulnerabilities in Medicare or Medicaid payment policies
  • Utilizes extensive knowledge of medical terminology, ICD-9-CM, ICD-10-CM HCPCS Level II and CPT coding along with analysis and processing of Medicare claims. Utilizes Medicare/Medicaid and Contractor guidelines for coverage determinations
  • Coordinates and compiles the written Investigative Summary Report to the PI Investigator upon completion of the records review
  • Incorporates leadership and communication skills to work with physicians and other health professionals as well as external regulatory agencies and law enforcement personnel
  • Provides training to UPIC staff on medical terminology, reading medical records, and policy interpretation
  • Provides expert witness testimony as required
  • Completes assignments in a manner that meets or exceeds the quality assurance goal of 98% accuracy
  • Maintains chain of custody on all documents and follows all confidentiality and security guidelines
  • Performs other duties as assigned by the Medical Review Supervisor that contribute to UPIC goals and objectives and comply with the Program Integrity Manual and Statement of Work guidelines and CMS directives and regulations
Requirements:
  • 2 years minimum experience with a state Medicaid agency or Managed Care Organization focused in Medicaid
  • 2 years minimum of working knowledge of ICD 10-CM/CPT coding experience
  • 4 years minimum experience auditing claims history or provider files to determine if the claim was payable and if any signed of fraud, waste or abuse are noted
  • Knowledge of, and the ability to correctly identify, Medicare and Medicaid coverage guidelines
  • Advance knowledge of medical terminology and experience in the analysis and processing of Medicare claims, utilization review/ quality assurance procedures, ICD 10-CM and CPT coding, Medicare coverage guidelines and payment methodologies (i.e., Correct Coding Initiative, DRG's, Prospective Payment Systems and Ambulatory Surgical center), NCPCP and other types of prescription drug claims
  • Ability to read Medicaid claims, both paper and electronic, and a basic knowledge of Medicaid is required
  • Should possess excellent verbal and written communication skills with an ability to write professional summary reports
  • Knowledge of and ability to use Microsoft Word, Excel, and Internet applications
  • Able to efficiently organize and manage workload and assignments
  • Must have and maintain a valid driver' license for the state of residence as on-site audits are part of the role as a nurse reviewer
Educational/Experience Qualifications:
  • Graduate from an accredited school of nursing and have an active license as a Registered Nurse (RN) required
  • Preference given to BSN or higher prepared nurses with recent medical review claims experience in Medicare or Medicaid reviews
Benefits
  • Medical, Dental, Vision plans
  • Life, LTD and STD paid by the employer
  • 401(k) with company match up to 4%
  • Paid Time Off and company paid holidays
  • Tuition assistance after 1 year of service

The salary range for this role is $78,000 to $85,000 annually. This is the lowest to highest salary we in good faith believe we would pay for this role at the time of this posting. We may ultimately pay more or less than the posted range, and the range may be modified in the future. An employee's pay position within the salary range will be based on several factors including, but not limited to, relevant education, qualifications, certifications, experience, skills, geographic location, performance, and business or organizational needs.
Pursuant to the San Francisco Fair Chance Ordinance, we will consider for employment qualified applicants with arrest and conviction records.
At this time, CoventBridge is not considering candidates who require visa sponsorship, currently or in the future, including but not limited to H-1B, H-2B, E-3, TN, O-1, F-1 (OPT/CPT, or J-1 Visa Statuses.)
About Us:
CoventBridge Integrity Systems delivers investigative services, technology, and expertise that help healthcare and government organizations protect critical programs, strengthen oversight, and address fraud, waste, abuse, and operational risk.
CoventBridge Integrity Systems is an equal opportunity employer. We evaluate qualified applicants without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, caste, disability, veteran status, and other legally protected characteristics and maintains a drug-free workplace.
CoventBridge Integrity Systems is committed to the full inclusion of all qualified individuals. As part of this commitment, CoventBridge Integrity Systems will ensure that persons with disabilities are provided reasonable accommodations. If reasonable accommodation is needed to participate in the job application or interview process, to perform essential job functions, and/or to receive other benefits and privileges of employment, please contact: Human Resources; 888-932-7364; humanresources@coventbridge.com.

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