CoventBridge Group

  • Medical Reviewer III - Medicare Medical Review RN- Chicago, Detroit, Des Moines, Kansas City, St. Louis, Indianapolis, Columbus, Cincinnati, Louisville

    Job Locations US-IL-Chicago
    Posted Date 2 months ago(8/8/2019 1:16 PM)
    Job ID
    # of Openings
  • Overview

    Medicare Medical Review RN - (Medical Reviewer III)  REMOTE

    Company Overview:


    CoventBridge Group is the leading worldwide full-service investigation solutions company providing: Surveillance, SIU and Compliance, Claims Investigation, Counter-Fraud Programs, Desktop Investigations, Social Media, Record Retrieval, Canvasses and Vendor Management programs.  With offices in the UK and U.S. the company provides top tier data privacy and security practices, deploys robust case management technology customized to clients’ needs and delivers worldwide coverage via its 1000 employees and affiliates worldwide.


    About the Opportunity:


    The Medicare 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 Group'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 remotely from a home office.  Ideal candidates will reside in one of the following areas:  Chicago, Detroit, Des Moines, Kansas City, St. Louis, Indianapolis, Columbus, Cincinnati, Louisville.




    • 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.


    • Graduate from an accredited school of nursing and has an active license as a Registered Nurse (RN).
    • Must have and maintain a valid driver' license for the associate's state of residence as onsite audits are part of the role as a nurse reviewer.
    • At least 4 years utilization/quality assurance review and ICD-9/10-CM/CPT-4 coding experience.
    • At least 4 years of experience in coding and abstracting, working knowledge of Diagnosis Related Groups (DRGs), Prospective Payment Systems, and Medicare coverage guidelines is required.
    • Advanced knowledge of medical terminology and experience in the analysis and processing of Medicare claims, utilization review/quality assurance procedures, ICD-9/10-CM and CPT-4 coding, Medicare coverage guidelines, and payment methodologies (i.e., Correct Coding Initiative, DRGs, Prospective Payment Systems, and Ambulatory Surgical Center), NCPDP and other types of prescription drug claims is required.
    • Ability to read Medicare claims, both paper and electronic, and a basic knowledge of the Medicare claims systems is required.
    • Knowledge of and ability to use Microsoft Word, Excel and Internet applications.


    Educational Qualifications:

    •  Preference given to BSN or higher prepared nurses with recent medical review claims experience in Medicare or Medicaid reviews.




    • 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

    *CoventBridge is proud to be an EEO-AA employer M/F/D/V and maintains a Drug-Free Workplace.*





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