Performant Corporation is an Equal Opportunity Employer (Minorities/Females/Disabled/Veterans).

Start Over with Job Search
Returning Applicant?  Login Now

Medical Review Nurse (Government Outpatient Clinical Focus)
Job Code:2022-50-R-081
Location:United States - Remote
Status:Regular Full Time

The Medical Review Nurse Auditor objectively and accurately completes medical record reviews on assigned audits while meeting quality and productivity performance goals.  Makes determinations based on clinical expertise and knowledge while using audit tools and resources available.  Communicates and supports the identification of additional audit opportunities and participates in development of ideas as necessary.   

  • Conduct medical chart reviews.
  • Clinically validate the medical necessity appropriateness of services rendered in an outpatient setting.
  • Accurately document clinical audit determinations within the audit tracking system, and maintain thorough and objective documentation of findings.
  • Create narrative rationale to correspond audit determinations.  
  • As needed, support findings during the appeals process.
  • Serve as a clinical resource; provide clinical expertise, and clinical guidance to the team.
  • Works collaboratively with the audit team to identify vulnerabilities and/or cases subject to potential Fraud Waste and Abuse (FWA).
  • Monitors, tracks and reports on all work conducted.
  • Consults with our clients, physicians, other clinical resources and contractors as necessary.
  • Participates in process improvement activities and encourages ownership of and group participation in improvement initiatives.
  • As needed, assist with quality assurance functions, development of medical review and training.
  • Maintain a current knowledge of Medicare and Commercial regulations, policies and procedures
  • Identify and recommends opportunities for cost savings and improving outcomes.
  • Attend conference calls and meetings as requested.
  • Maintain RN license to ensure eligibility to perform audits on behalf of Performant
  • Other duties, responsibilities, and qualifications may be required and/or assigned as necessary


*Note - All employees and contractors for Performant Financial may and/or will have access to Sensitive, Proprietary, Confidential and/or Public data. As such, all employees and contractors will have ownership and responsibility to report any violations to the Confidentiality and Integrity of Sensitive, Proprietary, Confidential and/or Public data at all times.  Violations to Performant’s policy related to the Confidentiality or Integrity of data may be subject to disciplinary actions up to and including termination.

Required Skills and Knowledge:

 - Strong preference for experience performing utilization review for an insurance company, Tricare, MAC or organizations performing similar functions

 - Experience with utilization management systems or clinical decision making tools such as Medical Coverage Guidelines (MCG) or InterQual.

 - Experience with 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.

 - Not currently sanctioned or excluded from the Medicare program by the OIG.

 - Active unrestricted RN license in good standing.

 - 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

 - Work independently and with team members effectively.

Additional Requirements:

• Ability to obtain and maintain client required clearances as well as pass company regular background and/or drug screening.

• Completion of Teleworker Agreement upon hire, and adherence to the Agreement (and related policies and procedures) including, but not limited to: able to navigate computer and phone systems as a user to work remote independently using on-line resources, must have high-speed internet connectivity, appropriate workspace able to be compliant with HIPAA, safety & ergonomics, confidentiality, and dedicated work focus without distractions during work hours.

Physical Requirements:

**NOTE: Must be able to meet requirements for and perform work assignments in accordance with Company policies and expectations on a home remote basis (and must meet Performant remote-worker requirements) until at which time staff may be notified and required to work from a Performant office location on an ad-hoc or periodic basis.

Basic office equipment required to perform remote work is provided by the company.

• Job is performed in a standard busy office environment with moderate noise level (or may be home-office setting subject to Company approval and Teleworker Agreement), sits at a desk during scheduled shift, uses office phone or headset provided by the Company for 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 mouse.

• Reads and comprehends information in electronic (computer) or paper form (written/printed). 

• Sit/stand 8 or more hours per day; has the option to stand as needed while on calls; reach as needed to use office equipment.

• Consistently viewing a computer screen and types frequently, but not constantly, using a keyboard to update accounts.

• Consistently communicates on the phone as required primarily within the department and company and may include client contacts or other third-party depending on assignment with account holders, may dial manually when need or use dialer system; headset is also provided.

• Occasionally lift/carry/push/pull up to 10lbs.
Education and Experience:

  •  Active unrestricted RN license in good standing.
  • 3+ years  diversified nursing experience providing direct care in an outpatient or inpatient setting.
  • 1+ years experience performing medical record reviews.
  • 1+ years experience in healthcare claims that demonstrates expertise in, ICD-9/ICD-10 coding, HCPCS/CPT coding and medical billing experience for an Insurance Company or hospital required.
  • Experience in conducting medical audits, investigations, reviewing and researching post service claims for aberrant billing patters, thorough review of the medical record documentation preferred.
  • Experience with utilization management systems or clinical decision making tools such as MCG or InterQual.
  • Proven ability to review, analyze, and research coding issues, a plus but not required.
  • Reimbursement policy and/ or claims software analyst experience, a plus but not required
  • Previous experience in either a provider or payer environment in claim processing, auditing, edit development, and/or coding and reimbursement policy a plus but not required


Other Requirements:

Performant 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 clearances (as applicable).

• Must submit to and pass pre-hire background check, as well as additional checks throughout employment.

• Must be able to pass a criminal background check; must not have any felony convictions or specific misdemeanors, nor on state/federal debarment or exclusion lists.

• Must submit to and pass drug screen pre-employment (and throughout employment).

• Performant is a government contractor. Certain client assignments for this position requires submission to and successful outcome of additional background and/or clearances throughout employment with the Company.
Employment VISA Sponsorship is not available for this position

Job Profile is subject to change at any time.

Performant Financial Corporation is an Equal Opportunity Employer. 
Performant Financial Corporation is committed to creating a diverse environment and is proud to be an equal opportunity employer. All qualified applicants will receive consideration for employment without regard to race, color, national origin, ancestry, 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.