Medical Review II (Medicare)

Essential Duties and Responsibilities:
Reviews all claims subject to medical review in accordance with applicable statutes, regulations, CMS guidelines, and coverage requirements.
Conducts pre-claim review (PCR) for Inpatient Rehabilitation Facility (IRF) services within designated review areas.
Completes complex medical reviews of PCR requests within 2 business days of receipt, including resubmissions.
Completes pre-payment complex medical reviews of Additional Documentation Request (ADR) responses within 30 calendar days of receipt.
Completes post-payment complex medical reviews of ADR responses within 60 calendar days of receipt.
Completes complex medical reviews of reopened ADR responses within 60 calendar days of receipt.
Renders affirmative or non-affirmative determinations on each PCR request, assigning a Unique Tracking Number (UTN) per billing period, and treats incomplete documentation packages as non-affirmed.
Conducts provider phone calls to communicate review determinations and provide education on non-affirmed decisions.
Maintains accurate and timely documentation of all review activity in accordance with contract and CMS requirements.

Minimum Qualifications:
Active, unrestricted Registered Nurse (RN) license (compact license preferred).
Minimum of 2–3 years of clinical nursing experience, with a background in rehabilitation, acute care, or case management preferred.
Working knowledge of CMS coverage guidelines, IRF medical necessity criteria, and Medicare Administrative Contractor (MAC) review processes.
Strong analytical and clinical decision-making skills, with the ability to interpret medical records against regulatory criteria.
Excellent written and verbal communication skills, including experience conveying review determinations directly to providers.
Proficiency with Microsoft Office and claims/medical review software systems.
Ability to consistently meet contractual review turnaround deadlines in a production-driven environment.

Preferred Qualifications:
Experience specifically with Inpatient Rehabilitation Facility (IRF) documentation and CMS Review Choice Demonstration (RCD) programs.
Certification in case management, utilization review, or a related specialty (e.g., CCM, ACM).
Minimum of 2–3 years of clinical nursing experience, with rehabilitation, acute care, or case management background preferred.