Medical Review Specialist V

Responsibilities:

• Review medical documentation for medical necessity using CMS policies and clinical knowledge.
• Analyze Standard Claims Processing files to detect potential fraudulent billing patterns.
• Participate in Quality Assurance and IRR monitoring as requested.

Qualifications:

• Registered Nurse with current licensure in one or more states or D.C.
• Minimum 10 years of clinical experience and 7 years of claims knowledge.
• Strong communication, organization, and time management skills.

Work Environment:

• Casual/part-time remote position supporting the Department of Justice.
• Requires sitting for long periods and maintaining confidentiality of sensitive materials.