Essential Duties and Responsibilities:

• Reviews all claims subject to medical review in accordance with applicable statutes, regulations, CMS guidelines, and coverage requirements.
• Conducts pre-claim review (PCR) for Inpatient Rehabilitation Facility (IRF) services within designated review areas.
• Completes complex medical reviews of PCR requests within 2 business days of receipt, including resubmissions.
• Completes pre-payment complex medical reviews of Additional Documentation Request (ADR) responses within 30 calendar days of receipt.
• Completes post-payment complex medical reviews of ADR responses within 60 calendar days of receipt.
• Completes complex medical reviews of reopened ADR responses within 60 calendar days of receipt.
• Renders affirmative or non-affirmative determinations on each PCR request, assigning a Unique Tracking Number (UTN) per billing period, and treats incomplete documentation packages as non-affirmed.
• Conducts provider phone calls to communicate review determinations and provide education on non-affirmed decisions.
• Maintains accurate and timely documentation of all review activity in accordance with contract and CMS requirements.

Minimum Qualifications:

• Active, unrestricted Registered Nurse (RN) license (compact license preferred).
• Minimum of 2–3 years of clinical nursing experience, with a background in rehabilitation, acute care, or case management preferred.
• Prior experience in Medicare medical review, utilization review, or claims review strongly preferred.
• Working knowledge of CMS coverage guidelines, IRF medical necessity criteria, and Medicare Administrative Contractor (MAC) review processes.
• Strong analytical and clinical decision-making skills, with the ability to interpret medical records against regulatory criteria.
• Excellent written and verbal communication skills, including experience conveying review determinations directly to providers.
• Proficiency with Microsoft Office and claims/medical review software systems.
• Ability to consistently meet contractual review turnaround deadlines in a production-driven environment.

Preferred Qualifications:

• Experience specifically with Inpatient Rehabilitation Facility (IRF) documentation and CMS Review Choice Demonstration (RCD) programs.
• Certification in case management, utilization review, or a related specialty (e.g., CCM, ACM).