Registered Nurse Medical Reviewer in Cincinnati, OH

A company is looking for a Medical Review Specialist V to review and analyze Medicare claims for payment determinations. Key Responsibilities Conduct medical record claims review to determine correct coding and medical necessity based on CMS policies and guidelines Analyze claims for suspected fraudulent billing practices and complete summary reports of findings Ensure compliance with departmental policies, Medicare, and DOJ guidelines while maintaining confidentiality of information Required Qualifications Registered Nurse (RN) with current licensure in one or more states or D.C At least 10 years of clinical experience and a minimum of 7 years of claims knowledge Medical review experience is required; previous fraud review / investigation experience is preferred Ability to maintain confidentiality and handle sensitive information No adverse actions pending or taken against licensure by any State or Federal board