Join the Avosys Team as a Remote Registered Nurse - Medical Review Specialist Avosys is a leading integrator of professional, technological, and management solutions services, proudly serving Federal, Commercial, Local, and State clients nationwide. Since our founding in 1998, we've prioritized the growth and well-being of our people, recognizing that they are the foundation of our success. We're now seeking a highly skilled and compassionate Registered Nurse - Medical Review Specialist to join our team remotely from Bexar County, Texas. As a Medical Review Specialist, you will play a crucial role in reviewing Medicare claims, ensuring compliance with CMS requirements, and providing high-quality patient care. About Our Company Culture and Values At Avosys, we value our employees' well-being and strive to create a work environment that supports work-life balance, professional growth, and community engagement. Our company culture is built on the principles of respect, integrity, and excellence. We believe in fostering a collaborative and inclusive work environment that encourages innovation, creativity, and teamwork. Our employees are our greatest asset, and we're committed to providing them with the resources and support they need to succeed. Benefits and Perks We offer a comprehensive benefits package, including: Competitive salary and bonuses Medical, dental, vision, life, short-term disability, and long-term disability insurance 401(k) retirement plan Flexible work arrangements, including remote work options No weekend, holiday, or on-call requirements Guaranteed 8-hour shifts Opportunities for professional growth and development Job Summary We're seeking a highly skilled Registered Nurse - Medical Review Specialist to review Medicare Part A and Part B claims, ensuring compliance with CMS requirements and regulations. As a Medical Review Specialist, you will be responsible for performing clinical reviews of Medicare claims, completing documentation of clinical decisions, and providing high-quality patient care. This is a unique opportunity to work remotely and make a meaningful impact on the lives of Medicare beneficiaries. Key Responsibilities As a Registered Nurse - Medical Review Specialist, your primary responsibilities will include: Performing clinical reviews of Medicare Part A and Part B claims for Medical Review, Redeterminations/Appeals, and Prior Authorization requests Completing a projected number of clinical review hours while meeting timeliness and accuracy standards Reviewing medical record documentation within CMS timeliness parameters Utilizing applicable Medicare policies to ensure compliance with all Medicare regulations and documentation requirements Reviewing documentation for medical necessity per guidelines outlined in the Social Security Act 1862(a)(1) Ensuring that all documentation includes a valid signature consistent with the signature requirements Documenting rationale for processing decisions Providing a claim sample of three claims to Companies via established protocols and timeliness parameters for quality review prior to finalization of documentation of reason for payment, reduction, or denial of service Completing documentation of the reason for payment, reduction, or denial of service for all claims on an electronic decision template Returning documented decisions electronically to Companies via established protocols and timeliness parameters Completing review results letters in the Companies' letter writing system within specified timeframes Documenting all case activity in Companies' provider tracking system on the day the activity occurs Completing one-on-one provider education within 30 days of sending out review results letters Responding to provider inquiries related to case and/or claims throughout the course of review If additional clinical guidance is required, completing the Contractor Medical Director (“CMD”) assistance form, tracking response, and updating review accordingly Conducting telephone development for missing or additional records for easily curable errors Notating date of receipt of additional documentation received in the Companies' provider tracking system Upon request by Companies, initiating or participating in provider teaching activities, creating written teaching material, providing one-on-one education or education to a group as a result of an MR review If fraud activity is suspected, immediately completing initial referral packet for external entity referral and returning the packet to the Companies Completing referrals to Companies' provider outreach and education (“POE”) area in provider tracking system for cases that have a moderate or major error rate Participating in all monthly departmental training and meetings, and all Staff will participate as requested Submitting all cases for review and approval for quality and closure of cases Requirements and Qualifications To be successful in this role, you will need: Essential Qualifications: Minimum of two (2) years' clinical experience as a Registered Nurse Active and current Registered Nurse license Excellent written and oral communication skills Demonstrated experience with evaluating medical and health care delivery issues Strong computer skills, including Microsoft Office proficiency Preferred Qualifications: Experience with Medicare claims review and quality assurance Knowledge of CMS requirements and regulations Experience with electronic health records and medical billing systems Skills and Competencies To excel in this role, you will need: Strong analytical and critical thinking skills Excellent communication and interpersonal skills Ability to work independently and as part of a team Strong organizational and time management skills Ability to prioritize tasks and meet deadlines Career Growth Opportunities and Learning Benefits At Avosys, we're committed to providing our employees with opportunities for professional growth and development. As a Medical Review Specialist, you'll have access to: Comprehensive training and onboarding program Ongoing education and training opportunities Career advancement opportunities within the company Competitive salary and benefits package Work Environment and Company Culture We offer a remote work environment with flexible scheduling options. Our company culture is built on the principles of respect, integrity, and excellence. We believe in fostering a collaborative and inclusive work environment that encourages innovation, creativity, and teamwork. Compensation and Benefits We offer a comprehensive compensation and benefits package, including: Competitive salary Medical, dental, vision, life, short-term disability, and long-term disability insurance 401(k) retirement plan Flexible work arrangements, including remote work options How to Apply If you're a motivated and compassionate Registered Nurse looking for a new challenge, we encourage you to apply for this exciting opportunity. Please submit your application, including your resume and cover letter, to [
[email protected]](mailto:
[email protected]) or call (210) 888-0775 for assistance. Avosys is an equal opportunity employer and welcomes applications from diverse candidates. We're committed to providing a work environment that is inclusive and respectful of all employees. Apply for this job