Medical Review Nurse

✓ Verified Job

Canonical indexed version, validated from employer's careers page.

Source: Company careers pageValidated by: Fursa AI

Last checked: 20 minutes agoStatus: Live

Job Summary

Shape the future of at-home care by reviewing surgical dressing orders for CMS compliance. Translate LCDs, policy articles, and MAC playbooks into practical checklists and “go/no-go” criteria, then run pre-bill controls (clinical completeness and billing correctness). Lead UPIC/MAC ADR responses pre- and post-pay, coach the internal billing team, and enable customer-facing teams with documentation-focused training while tracking denial and appeal metrics.

Location: United States

Workplace: Remote

Employment Type: Full time

Job Function: Healthcare (Clinical, Medical, Wellness)

Seniority: Mid level

Key Responsibilities

•Interpret and operationalize LCD L33831 plus the Policy Article for surgical dressings, publishing practical coverage rules and documentation phrases.
•Set up “go/no-go” criteria and codify coverage logic for materials and modifiers, including sizing and quantity/frequency math.
•Build and pilot a 2-gate QA process (clinical completeness and billing correctness) for surgical-dressing claims and create/update outreach templates.
•Lead UPIC/MAC ADR responses pre- and post-pay, coach the internal billing team, and maintain a reusable appeals library with policy citations and exemplars.
•Train customer-facing team members and billers on LCD-satisfying documentation, and define/track metrics such as denial rate, appeal win rate, ADR turnaround, signed POD packets, and top defects.],
•travel
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Key Requirements

•3-5+ years medical-review experience at a UPIC or MAC (e.g., Safeguard Services, Qlarant, CoventBridge; Noridian, CGS, NGS, WPS, Novitas, Palmetto).
•Hands-on adjudication of surgical dressings, including collagen, alginate/fiber-gelling, foam, bordered foam, gauze, and film.
•Expertise in proof-of-delivery standards, SWO requirements, frequency/sizing rules, and common denial rationales (e.g., two-cover stacking, over-frequency without rationale, DOS/POD mismatch).
•Crisp, policy-anchored writing with calm, deadline-focused execution and disciplined handling of PHI.
•Ability to translate LCDs/policy articles and MAC playbooks into checklists, documentation phrases, and operational “go/no-go” criteria.

Experience:3+ years

Skills:Policy-anchored writingCalm under deadlineDisciplined handling of PHIAccuracy and attention to detail

Company Brief

Verse Medical

Develops medical devices and related technologies aimed at improving clinical procedures and patient outcomes. Focuses on designing, prototyping, and bringing healthcare hardware solutions to market for use in hospitals and clinical settings.

Industry: Medical Devices

Website

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Verse Medical

2 weeks ago

Medical Review Nurse

✓ Verified Job

Canonical indexed version, validated from employer's careers page.

Source: Company careers pageValidated by: Fursa AI

Last checked: 20 minutes agoStatus: Live

Job Summary

Location: United States

Workplace: Remote

Employment Type: Full time

Job Function: Healthcare (Clinical, Medical, Wellness)

Seniority: Mid level

Key Responsibilities

•Interpret and operationalize LCD L33831 plus the Policy Article for surgical dressings, publishing practical coverage rules and documentation phrases.
•Set up “go/no-go” criteria and codify coverage logic for materials and modifiers, including sizing and quantity/frequency math.
•Build and pilot a 2-gate QA process (clinical completeness and billing correctness) for surgical-dressing claims and create/update outreach templates.
•Lead UPIC/MAC ADR responses pre- and post-pay, coach the internal billing team, and maintain a reusable appeals library with policy citations and exemplars.
•Train customer-facing team members and billers on LCD-satisfying documentation, and define/track metrics such as denial rate, appeal win rate, ADR turnaround, signed POD packets, and top defects.],
•travel
•salary_currency
•salary_minimum
•:null,

Key Requirements

•3-5+ years medical-review experience at a UPIC or MAC (e.g., Safeguard Services, Qlarant, CoventBridge; Noridian, CGS, NGS, WPS, Novitas, Palmetto).
•Hands-on adjudication of surgical dressings, including collagen, alginate/fiber-gelling, foam, bordered foam, gauze, and film.
•Expertise in proof-of-delivery standards, SWO requirements, frequency/sizing rules, and common denial rationales (e.g., two-cover stacking, over-frequency without rationale, DOS/POD mismatch).
•Crisp, policy-anchored writing with calm, deadline-focused execution and disciplined handling of PHI.
•Ability to translate LCDs/policy articles and MAC playbooks into checklists, documentation phrases, and operational “go/no-go” criteria.

Experience:3+ years

Skills:Policy-anchored writingCalm under deadlineDisciplined handling of PHIAccuracy and attention to detail

Company Brief

Verse Medical

Industry: Medical Devices

Website