Williams Consulting, LLC.

Sr. Medical Review Nurse

Posted on

April 2, 2025

Job Type

Full-Time

Role Type

Clinical Operations

License

RN

State License

Maryland

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Company Description

Williams Consulting LLC is seeking candidates for Medical Review Nurse positions to join our growing team. This is a 100% remote position in support of the Centers for Medicare and Medicaid Services. Williams Consulting LLC is an 8a, HUBZone and Woman-owned Small Business with Federal, State, Local and Commercial clients. We take great pride in our ability to provide exceptional customer service and we value our employees and recognize their contributions to the success of our clients and our company. We offer competitive salaries and support flexible work locations and scheduling, when possible. We offer competitive benefits including Medical, Vision, and Dental coverages through national plans. Life, AD&D, Short & Long Term Disability Insurance, PTO, and 401k.

Job Description

As a member of our Federal Team the Medical Review Nurse (MRN) will support to the Medical Claim/ Medical Review operations. This position applies clinical knowledge to assess and ensure services/items billed are reasonable and necessary, supported by national and local policies, are under accepted billing and coding practices, and meet standards of medical care. Responsibilities include but are not limited to making determinations based on established policies and procedures, reviewing Medicare Beneficiary medical records, evaluating medical coding practices and making determinations. The Medical Review Nurse role may also involve Case/Project discussions with impacted stakeholders.

Requirements

Minimum Job Requirements: Active, current, valid, unrestricted Registered Nurse (RN) License A minimum requirement of three to five (3-5) years of recent medical review experience/claims review/coding review for payment accuracy experience is mandatory in this role (CERT Experience is a PLUS) Previous Medicare Part A and B Claims Review experience, can include prior authorization or appeals experience, utilizing established criteria to make medical review determination Proven Analytical and Research Skills Excellent written and verbal communication skills Experience working with multiple research/processing systems Experience working with MS Word, Excel, and PowerPoint Successful Candidates Will Additionally Have the Following: Ability to successfully pass the required background checks Strong analytical skills Strong written and oral communication skills Proven track record in Fraud, Waste and Abuse related activities Computer skills with an emphasis on data entry, tracking and analysis and the ability to work well independently No Conflicts of Interest related due to other active employment (full or part-time)

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Responsibilities

Reviews Complex Medical Record and Billing/Claims Cases/Projects Evaluates Coding Practices Applies Clinical guidelines and other coverage/Medical criteria in reviewing cases/projects Interacts with various stakeholders as required to support case review Completes inquiry letters, investigation finding letters, and case summaries Investigates and refers all potential fraud leads to the appropriate identified resources Responsible for case specific and other required data entry, tracking and reporting Performs other related Program duties as assigned

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