Registered Nurse (RN) Medicare Quality Assurance Reviewer (Medtech)

TL;DR

Registered Nurse (RN) Medicare Quality Assurance Reviewer (Medtech): Providing clinical expertise and conducting quality assurance reviews for Medicare utilization management with an accent on compliance with CMS guidelines and medical necessity standards. Focus on identifying clinical improvement opportunities, managing vendor relationships, and ensuring high standards of clinical excellence.

Location: Must be based in the USA

Salary: $92,000 - $120,000 USD

Company

hirify.global is a healthcare company reinventing insurance by combining data and technology to provide personalized, high-quality care for seniors.

What you will do

• Provide clinical expertise support for vendors and Medical Directors.
• Create and assign inter-rater reliability reviews to RN reviewers and Medical Directors.
• Complete monthly MD quality assurance reviews to ensure compliance with Medicare regulations.
• Serve as a subject matter expert for clinical medical record reviews.
• Identify clinical opportunities for improvement and communicate findings to management.
• Monitor and track CMS Medicare clinical updates to implement necessary process changes.

Requirements

• Active and valid RN license required.
• Minimum of 3 years of Medicare Utilization Management medical necessity review experience required.
• Strong knowledge of applying CMS guidelines, NCD, and LCD to Medicare medical necessity reviews required.
• Quality Assurance experience required.
• Excellent interpersonal and communication skills.
• Experience in leading vendor relationships and building clinical review teams.

Nice to have

• Experience working in a Medicare Advantage plan.
• RN clinical experience in a hospital setting.
• Previous experience working remotely.

Culture & Benefits

• Competitive base salary, equity opportunities, and performance-based bonuses.
• Comprehensive medical, dental, and vision coverage.
• Remote-first culture with flexible time-off policy and No-Meeting Fridays.
• 401k matching and Employee Stock Purchase Plan (ESPP).
• Professional development funding and mentorship programs.
• Stipends for office setup, cell phone, and internet.