Medical Review Nurse Analyst

About the role

The Medical Review Nurse Analyst conducts clinical reviews of medical records to verify compliance with Medicare guidelines, ensure accurate billing, and provide education to healthcare providers on documentation and coding requirements.

Key responsibilities

• Perform detailed reviews of medical records and documentation to determine medical necessity of services.
• Review submitted claims to confirm services are medically necessary and correctly coded per Medicare guidelines.
• Prepare written clinical summaries and determinations with clear rationale for approvals, denials, or modifications.
• Educate providers through the Targeted Probe and Educate (TPE) program and monitor their progress.
• Maintain compliance with federal and state regulations, CMS guidelines, and company policies.
• Stay current on clinical guidelines, medical policy updates, and industry best practices.

Required profile

• Associate’s or Bachelor’s degree in Nursing (ASN/BSN) with an active RN license in good standing.
• At least one year of clinical experience in a healthcare setting (hospital, homecare, skilled nursing, etc.).
• Excellent written and verbal communication skills, with the ability to convey complex medical information clearly.
• Strong attention to detail and organizational abilities to manage multiple cases simultaneously.
• Basic knowledge of medical/clinical review processes.

Required skills

• Proficiency with Microsoft Outlook.
• Proficiency with Microsoft Teams.
• Proficiency with Microsoft OneNote.
• Proficiency with Microsoft Word.
• Proficiency with Microsoft Excel.

What we offer

• Remote work option across approved U.S. states.
• Performance bonus and merit increase opportunities.
• 401(k) retirement plan.
• Competitive salary range.