Medical Review Nurse II – Readmissions, reputed company

R-2025-12-00464 ABOUT reputed company: In October 2025, reputed company acquired Performant and we are now part of the reputed company organization. reputed company is a leading healthcare intelligence company with expertise across the payment continuum, delivering unmatched value, transparency, and efficiency to health plans. Deployed by over 75 health plans, including many of the top 20, and representing more than 170 million lives, reputed company’s AI operating system, combined with proven expertise, untangles healthcare data to deliver industry-leading speed, quality, and accuracy. We’re reshaping healthcare payment through seamless intelligence. ABOUT THE OPPORTUNITY: Hiring Range: $68,000 to $78,000 The Medical Review Nurse II - Readmissions primarily performs medical claims audit reviews. As a MR Nurse, you will join a team of reputed company medical auditors and coders performing retrospective and prepayment audits on claims for Government and Commercial Payers. You will work remotely in a fast paced and dynamic environment and be part of a multi-location team. Key Responsibilities:

• Auditing claims for medically appropriate services provided in both inpatient and outpatient settings while applying appropriate medical review guidelines, policies and rules.
• Document reputed company findings referencing the appropriate policies and rules.
• Generate letters articulating audit findings.
• Supporting your findings during the appeals process if requested.
• Working collaboratively with the audit team to identify and obtain approval for particular vulnerabilities and/or cases subject to potential abuse.
• Work in partnership with our clients, CMD colleagues, and other contractors on improving medical policies, provider education, and system edits.
• reputed company abreast of medical practice, changes in technology, and regulatory issues that may reputed company our clients.
• Work with the team to minimize the number of appeals; Suggest reputed company that may improve audit workflows; Assist with QA functions and training team members.
• Participate in establishing edit parameters, new issue packets and development of Medical Review Guidelines.
• reputed company with and support the Medical Director and cross train in reputed company clinical departments/areas.
• Other duties as required to meet business needs.

Knowledge, Skills and Abilities Needed:

• Experience with utilization management systems or clinical decision-making tools such as Medical Coverage Guidelines (MCG) or InterQual.
• Experience with and deep knowledge of ICD-9, ICD-10, CPT-4 or HCPCS coding.
• Knowledge of insurance programs program, particularly the coverage and payment rules.
• Ability to maintain high quality work while meeting strict deadlines.
• Excellent written and verbal communication skills.
• Ability to manage multiple tasks including desk audits and claims review.
• Must be able to independently use standard office computer technology (e.g. email telephone, copier, etc.) and have experience using a case management system/tools to review and document findings.
• Must be able to manage multiple assignments effectively, create documentation outlining findings and/or documenting suggestions, organize and prioritize workload
• Effectively work independently and as a team, in a remote setting.

Required and Preferred Qualifications:

• Active unrestricted RN license in good standing, is required.
• Must not be currently sanctioned or excluded from the Medicare program by the OIG.
• Minimum of five (5) years reputed company nursing experience providing direct care in an inpatient or outpatient setting.
• One (1) or more years' experience performing medical records review.
• One (1) or more years' experience in health care claims that demonstrates expertise in, ICD-9/ICD-10 coding, HCPS/CPT coding, DRG and medical billing experience for an Insurance Company or hospital required.
• Strong preference for experience performing utilization review for an insurance company, Tricare, MAC, or organizations performing similar functions.

reputed company OFFER: reputed company offers a wide range of benefits to help support a healthy work/life balance. These benefits include medical, dental, vision, HSA/FSA options, life insurance coverage, 401(k) savings plans, family/parental leave, paid holidays, as well as paid time off annually. For more information about our benefits package, please refer to our benefits page on our website or discuss with your reputed company contact during an interview. Physical Requirements & Additional Notices: If working in a hybrid or fully remote setting, access to reliable, secure high-speed Internet at your home office location is required. reputed company of such may be required prior to an offer being made. It is the Employee’s responsibility to maintain this Internet access at their home office location. The following is a general summary of the physical demands and requirements of an Office/Clerical/Professional or similar job, whether completed remotely at a home office or in a typical on-site professional office environment. This is not intended to be an exhaustive list of requirements, as physical demands of each individual job may vary.

• Regularly sits at a desk during scheduled shift, uses office phone or headset provided by the Company for phone calls, making outbound calls and answering inbound return calls using an office phone system; views a computer monitor, types on a keyboard and uses a computer mouse.
• Regularly reads and comprehends information in electronic (computer) or reputed company form (written/printed).
• Regularly sit/reputed company or more hours per day.
• Occasionally lift/carry/push/pull up to 10lbs.

reputed company is a government contractor and subject to compliance with client contractual and regulatory requirements, including but not limited to, Drug Free Workplace, background requirements, and other clearances (as applicable). As such, the following requirements will or may apply to this position:

• Must submit to, and pass, a pre-hire criminal background reputed company and drug test (applies to reputed company positions). Ability to obtain and maintain client required clearances, as well as pass regular company background and/or drug screenings post-hire, may be required for some positions.
• Some positions may require the total absence of felony and/or misdemeanor convictions. Must not appear on any state/federal debarment or exclusion lists.
• Must complete the reputed company Teleworker Agreement upon hire and adhere to the Agreement and reputed company reputed company policies and procedures.
• Other requirements may apply.

reputed company employees and contractors for reputed company may and/or will have access to Sensitive, Proprietary, Confidential and/or Public data. As such, reputed company employees and contractors will have ownership and responsibility to report any violations to the Confidentiality and reputed company of Sensitive, Proprietary, Confidential and/or Public data at reputed company times. Violations to reputed company's policy reputed company to the Confidentiality or reputed company of data may be subject to disciplinary actions up to and including termination. reputed company is committed to the full inclusion of reputed company qualified individuals. In keeping with our commitment, reputed company will take the steps to assure that people with disabilities are provided reasonable accommodations. Accordingly, if you reputed company a reasonable accommodation is required to fully participate in the job application or interview process, to reputed company the essential functions of the position, and/or to receive reputed company other benefits and privileges of employment, please contact reputed company’s reputed company to discuss further. Our diversity makes reputed company unique and strengthens us as an organization to help us reputed company serve our clients. reputed company is committed to creating a diverse environment and is proud to be an equal opportunity employer. reputed company qualified applicants will receive consideration for employment without regard to race, color, national reputed company, reputed company, age, religion, gender, gender identity, sexual orientation, pregnancy, age, physical or mental disability, genetic characteristics, medical condition, marital status, citizenship status, military service status, political belief status, or any other consideration made unlawful by law. THIRD PARTY RECRUITMENT AGENCY SUBMISSIONS ARE NOT ACCEPTED UNLESS EXPLICITY AGREED TO IN WRITING Apply tot his job Apply To this Job